Emergency Drug Guidelines - World Health Organization

Emergency DrugGuidelines______________________________________________Second Edition2008Ministry of HealthGovernment of Fiji Islands2008"This document has been produced with the financial assistance of theEuropean Community and World Health Organization. The viewsexpressed herein are those of the Fiji National Medicine & TherapeuticsCommittee and can therefore in no way be taken to reflect the officialopinion of the European Community and the World Health Organization.”

DisclaimerThe authors do not warrant the accuracy of the information contained inthis 2 ndEdition of the Emergency Drug Guidelines and do no takeresponsibility for any death, loss, damage or injury caused by using theinformation in these guidelines.While every effort has been made to ensure that these guidelines arecorrect and in accordance with current evidence-based and clinicalpractices, the dynamic nature of medicine information requires thatusers exercise in all cases independent professional judgment andunderstand the individual clinical scenario when referring, prescribing orproviding information from the Emergency Drug Guidelines, 2 nd Edition.

PrefaceThe publication of the Second Edition of the Emergency DrugGuidelines represents the culmination of the efforts of the NationalDrugs and Therapeutics Committee (NDTC) to publish clinical drugguidelines for common diseases seen in Fiji. These guidelines aretargeted for health care professionals working at hospitals and at theprimary health care settings. It sets the gold standard for the use ofdrugs in the treatment of emergency medical conditions in Fiji.The guidelines have taken into account the drugs available in the FijiEssential Medicines Formulary (EMF), 2006 Edition, in recommendingtreatment approaches. All recommended therapies are either evidencebasedor universally accepted standards.It is hoped that these guidelines will be used by all health care workersin their daily care of patients suffering from emergency medicalconditions.DR. MARGARET CORNELIUSChairpersonNational Drugs and Therapeutics CommitteeMinistry of Health, Suva, Fiji2008

AcknowledgementsThe First Edition of these guidelines was drafted on behalf of theMinistry of Health (MOH) by Nick Adams, MBBS (Melb), FACEM,Principal Medical Officer, Accidents and Emergency Department,Colonial War Memorial Hospital in 1999.The Ministry of Health initially approached Dr Adams to prepare theseguidelines as part of an overall effort to develop treatment guidelines incritical areas. Dr Adams prepared these guidelines during hisemployment as a specialist emergency physician at CWM Hospital. TheMinistry of Health gratefully acknowledges the personal enthusiasm andinitiative of Dr Adams in producing these guidelines.Dr Adams was assisted by Elizabeth Pemberton, MBBS, FANZCA,Long-Term Advisor in Anaesthesia, Pacific Postgraduate MedicalCentre, Fiji School of Medicine, in the preparation of the draftguidelines.The guidelines have been reviewed by a subcommittee of the NationalDrugs and Therapeutics Committee.Subcommittee on the Preparation of the Second Edition of theEmergency Drug GuidelinesDr Gyaneshwar RaoConsultant Physician, Colonial War Memorial HospitalProf Robert MouldsClinical Pharmacologist, Professor of Medicine, Fiji School of Medicine

Dr Alan Mamerto GarvezConsultant Physician, Colonial War Memorial HospitalDr.Adam JenneySpecialist Physician, Colonial War Memorial HospitalDr Anne DrakeSenior Lecturer in Medicine, Fiji School of MedicineMs Vasiti Nawadra-TaylorPrincipal Pharmacist, Fiji Pharmaceutical Services

Table of Contents1 Emergency Drugs 11.1 Local anaesthetics 11.2 Sedatives and induction agents 11.3 Anticholinergics 21.4 Opiod analgesics 21.5 Antiemetics 31.6 Corticosteroids 31.7 Antiepileptics 31.8 Antiarrhyhtmics 41.9 Antihypertensives 51.10 Inotropic agents 51.11 Diuretics 61.12 Muscle relaxants 61.13 Neuroleptics 61.14 Anti-asthma drugs 71.15 Intravenous fluids 71.16 Tetanus prophylaxis 81.17 Drugs used in cardiac arrest 82 Cardiovascular Emergencies 102.1 Cardiac arrest 102.2 Cardiogenic shock 152.3 Unstable angina 162.4 Acute myocardial infarction 172.5 Cardiac arrhythmias 192.6 Acute pulmonary oedema 242.7 Hypertensive emergency 26

3 Respiratory Emergencies 273.1 Asthma 273.2 Exacerbation of chronic obstructivepulmonary disease 293.3 Croup 303.4 Epiglottitis 313.5 Oxygen therapy 324 Neurologic Emergencies 344.1 Seizures 344.2 Migraine 354.3 Oculogyric crisis 364.4 Tetanus 364.5 Acute bacterial meningitis in adults 375 Poisoning and Overdoses 385.1 General principles 395.2 Treatment of specific poisons 405.3 Poisons information 476 Endocrine Emergencies 486.1 Diabetic ketoacidosis 486.2 Hyperosmolar, hyperglycaemic state 506.3 Adrenal insufficiency 506.4 Hypoglycaemia 516.5 Thyroid storm 526.6 Myxydema coma (hypothyroid crisis) 52

6.7 Phaeochromocytoma 537 Fluid and Electrolyte Emergencies 547.1 Hyperkalaemia 547.2 Hypokalaemia 557.3 Hypercalcaemia 557.4 Hypocalcaemia 567.5 Fluid resuscitation 568 Miscellaneous Emergencies 578.1 Anaphylaxis 578.2 Pre-eclampsia 608.3 Septic shock 618.4 Acute psychosis 62Appendix 63

1 Emergency DrugsThis section is intended as a brief guide to some of the drugsmentioned in this book. It is by no means exhaustive and doesnot cover all contraindications or dosage alterations in specialsituations. Information about these areas should be obtainedelsewhere. The dosages below are guides only. Drug therapyshould always be adjusted to the individual patient situation.1.1 Local AnaestheticsLocal anaesthetic agents are used to provide anaesthesiathrough local wound infiltration, nerve blocks or regionaltechniques. Side effects from systemic absorption includeseizures and cardiac arrhythmias. Avoid accidental intravenousadministration by aspirating for blood prior to injection.Lignocaine is the agent of choice for local wound infiltration.The 1% solution is suitable for local infiltration of mostwounds. A concentration of 2% should be used for digitalnerve blocks and any other area where a smaller volume ofanaesthetic is desirable.Lignocaine with adrenaline should not be used on theextremities, i.e. nose, fingers, toes, ears or penis. The additionof adrenaline helps control bleeding and also extends theduration of anaesthesia.1

1.2 Sedatives and Induction AgentsThese drugs are used to depress the conscious state either forsedation or general anaesthesia. They should be used withgreat care as unconscious patients are unable to protect theirairway and because of the risk of causing hypoventilation andhypotension.Ketamine has anaesthetic and analgesic properties and is lesslikely to produce hypotension than other sedative agents. Italso has a mild bronchodilator action which makes it usefulwhen anaesthetising patients with asthma. Adverse effectsinclude increased salivation, laryngospasm, raised intracranialpressure and unpleasant hallucinations after recovery ofconsciousness. Ketamine should not be used in patients at riskof raised intracranial pressure (e.g. head injuries, meningitis) orin patients with ischaemic heart disease. It should not be givenunless personnel and facilities are available to protect thepatient’s airway.Ketamine should be given as an intravenous bolus. The usualdose is 2 mg per kg although some patients may require largeramounts. The onset of action is within 60 seconds and theduration is about 20 minutes.Thiopentone is a barbiturate with a short action because ofrapid distribution. Its main adverse effects relate tocardiorespiratory depression. It should be used with great carein patients who are hypotensive and should not be given unlesspersonnel and facilities are available to protect the patient’s2

airway. It is a potent anticonvulsant and is the drug of choicefor anaesthetising patients with status epilepticus.Thiopentone should be given as an intravenous bolus. Theusual dose is 3 to 5 mg per kg. The lower dose should be usedin the elderly. The onset of action is about 30 seconds and itseffects last for 5 to 10 minutes.Midazolam is a short-acting benzodiazepine. It has powerfulamnestic properties and produces less cardiorespiratorydepression than thiopentone. It is a fairly safe and usefulanaesthetic induction agent in the critically ill and is also usedto sedate children and agitated patients.Midazolam can be given intramuscularly or as an intravenousbolus. In children, intranasal midazolam is a usefulpremedication prior to suturing. The onset of action ofintravenous midazolam is 1 to 2 minutes and the effects of asingle dose last from 60 to 90 minutes. Intranasal midazolamhas its maximal effect within 10 minutes and lasts up to 2hours.In ADULTS: The intravenous dose is 2.5 to 15 mg. The doseshould be titrated to its effect. Smaller doses are usuallyrequired for the elderly, whereas alcoholics may require higherdoses. The intramuscular dose is 5 to 10 mg.In CHILDREN: The intravenous dose is 0.15 to 0.3 mg per kgup to 0.5 mg per kg. The intranasal dose is 0.2 to 0.4 mg per kg(to a maximum of 5 mg), slowly dropped into alternate nostrils3

over 15 seconds.1.3 AnticholinergicsAnticholinergic drugs block the effects of acetylcholine atmuscarinic receptors. The most commonly usedanticholinergic agent is atropine. This drug is used for thetreatment of bradycardia due to increased vagal tone, to blockthe cholinergic effects of drugs such as suxamethonium inchildren, and to reverse some of the adverse effects ofanticholinesterase (organophosphate) poisoning. Ipratropiumis used in the treatment of asthma and benztropine is used inthe treatment of oculogyric crisis.Atropine should be used with care in patients with ischaemicheart disease as it may cause a marked sinus tachycardia. Theusual adult dose is 0.6 mg intravenously as a bolus, repeated in5 minutes if necessary. A dose of 3 mg will produce completeblockade of muscarinic cholinergic receptors in an adult.Much larger doses are used in anticholinesterase poisoning.Atropine may be given via the endotracheal tube in anemergency; use twice the normal intravenous dose and dilute in10 ml of 0.9% saline. The paediatric dose is 20 microgramsper kg (to a maximum of 0.5 mg). The onset of action is within5 minutes and the duration of action is 2 to 4 hours.Benztropine is used in the treatment of oculogyric crisisprecipitated by prochlorperazine or similar drugs. Overdose of4

enztropine can cause central anticholinergic syndrome(confusion, hallucinations). The usual dose in adults is 1 to 2mg orally or intramuscularly. Children should be given 20micrograms per kg. Its duration of action is shorter than mostof the drugs that cause oculogyric crisis so a repeat oral doseshould be given 4 hours after the initial dose.1.4 Opioid AnalgesicsOpioid agents are mainly used for their analgesic and sedativeactions. The main side effects of these drugs are respiratorydepression, hypotension, nausea, vomiting, and constipation.NOTE: The use of parenteral opioid drugs is not recommendedin patients with chronic or recurrent painful conditions such asmigraine or back pain due to the risk of addiction.Morphine is usually used in the treatment of acute myocardialinfarction and pulmonary oedema. As an analgesic, it mayproduce less dysphoria than pethidine. The usual dose in adultsis 2.5 mg intravenous bolus repeated every few minutes asrequired to a maximum of 15 mg. The usual dose in children is0.05 mg per kg given intravenously every 5 minutes to amaximum of 0.2 mg per kg. The duration of action is about 3hours.Pethidine is mainly used as an analgesic. This is a highlyaddictive drug even after a few doses. The best method ofadministration is a dose of 25 to 50 mg intravenously every 3 to4 hours. Alternatively, a dose of 25 to 100 mg (maximum 1505

mg) may be given intramuscularly. The duration of action is 2to 3 hours with intramuscular dose and shorter with intravenousadministration.Fentanyl is a short acting narcotic used to sedate patients priorto painful procedures or intubation (often in combination withmidazolam). The usual dose of fentanyl is 1 microgram perkg. The duration of action is 30 to 40 minutes.1.5 AntiemeticsAnti-emetic drugs are used for the temporary relief of nauseaand vomiting.Metoclopramide (brand name: Maxolon) should not be givento children less than 16 years of age due to the high incidenceof acute dystonic reactions. It should also not be given topatients with bowel obstruction. Metoclopramide is useful inthe treatment of migraine and may also help the passage ofcalculi in renal colic. The usual dose is 10 mg by intravenousbolus or intramuscular injection or orally. Males weighingmore than 70 kg may require 15 or 20 mg. Females with lowbody weight or the elderly should be given 5 mg initially.Prochlorperazine (brand name: Stemetil) is also useful for thetreatment of vertigo as well as nausea and vomiting. It shouldnot be given to children less than 16 years of age. The oraldose is 5 to 10 mg 8-hourly. The intramuscular or intravenousdose is 12.5 mg every 8 hours.6

Promethazine (brand name: Phenergan) is a weakerantiemetic than prochlorperazine and is more sedating. It canbe given intravenously, intramuscularly or orally. The usualdose is 0.5 mg per kg.1.6 CorticosteroidsAlthough very useful in the treatment of asthma, anaphylaxisand many other conditions, the beneficial effects of these drugsare delayed for several hours at least. They should be usedwith care in patients with diabetes or peptic ulcer disease. Allagents have similar anti-inflammatory effects but differ in theirmineralocorticoid potency. Their mineralocorticoid (oraldosterone-like) effects may be undesirable and includesodium retention, oedema, and hypokalaemia.Equivalent anti-inflammatory doses are:100 mg hydrocortisone = 25 mg prednisolone = 4 mgdexamethasoneHydrocortisone has marked mineralocorticoid effects. Itshould be given intravenously over 5 minutes. The usual doseis 50 to 100 mg intravenously 6-hourly.Dexamethasone has virtually no mineralocorticoid effects. Itcan be given intramuscularly or intravenously as well as orally.The usual dose is 0.1 mg per kg every 8 hours.Prednisolone has moderate mineralocorticoid effects. It is7

given orally. The usual dose is 1 mg per kg daily to amaximum of 80 mg.1.7 AntiepilepticsThe first line drug in the treatment of epilepsy is diazepam.Phenytoin is useful for the treatment of idiopathic epilepsy butis less effective for seizures due to other causes. Barbituratessuch as phenobarbitone are powerful anti-epileptics but alsocause cardiorespiratory depression and marked depression ofconscious state often necessitating intubation and ventilation.Diazepam is a safe and effective agent for the termination ofseizures. It may be given intravenously or rectally. The oralroute is too slow in an emergency, whereas the intramuscularroute is painful and unpredictable. The onset of action whengiven intravenously is 1 to 2 minutes, whereas the rectal routemay take 5 to 10 minutes to have its full effect. The usualintravenous dose is 0.1 mg per kg repeated every 5 minutes ifrequired. The usual rectal dose is 0.5 mg per kg.Phenytoin must be given by slow intravenous injection. Theinfusion rate should not exceed 50 mg per minute in adults or 1mg per kg per minute in children. The drug should be dilutedin 0.9% saline only (not 5% dextrose) so that the concentrationis no greater than 5 mg per ml. Rapid infusion of concentratedsolutions may cause hypotension. The usual loading dose is15 mg per kg intravenously.8

1.8 Antiarrhythmics1.8.1 LignocaineLignocaine shortens the action potential duration. It is the drugof first choice in the treatment of ventricular tachycardiaalthough phenytoin is used in the treatment of ventriculartachycardia due to digoxin toxicity.Lignocaine 2% should be given intravenously over one minutein a dose of 1 mg per kg. A further 0.5 mg per kg may begiven after 5 minutes if necessary. Lignocaine has a very shorthalf-life so the intravenous bolus should be followed by aninfusion at a rate of 40 micrograms per kg per minute. Adverseeffects include confusion, coma, seizures and heart block butare not often encountered. Elderly patients may require lowerinfusion rates.1.8.2 PropranololPropranolol is occasionally used to delay conduction throughthe atrioventricular (AV) node in the treatment ofsupraventricular tachycardia or atrial fibrillation. It also maybe of benefit in the treatment of ventricular tachycardia due totheophylline overdose. Propranolol should not be used inpatients with decompensated left ventricular failure, asthma, orbradyarrhythmias. The dose should be titrated according toeffect. Give 10 micrograms per kg intravenously every 2minutes to a maximum of 100 micrograms per kg.9

1.8.3 AmiodaroneAmiodarone prolongs the action potential duration. It is usedin the treatment of both ventricular and atrial arrhythmias. Atleast some of its therapeutic effects are often delayed for up to24 hours. Amiodarone is not a negative inotrope and is welltolerated by patients with cardiac failure. Intravenousadministration is occasionally associated with hypotension dueto vasodilation. The usual loading dose of amiodarone is 5 mgper kg given intravenously over 30 minutes.1.8.4 VerapamilVerapamil is a calcium channel antagonist and depresses sinusnode automaticity and AV node conduction. It is thereforeused to treat supraventricular tachyarrhythmia. It is a powerfulnegative inotrope and should be used with great care in patientswith impaired left ventricular function.Verapamil should not be given to children less than 2 years ofage. It should not be given to patients with left ventricularfailure, bradycardia, or hypotension. The effectiveness ofvagal manoeuvres is increased following the administration ofverapamil. The usual dose in adults is 1 mg intravenousboluses every minute to a maximum of 10 mg.1.8.5 DigoxinDigoxin is used to control the ventricular rate in atrialfibrillation. It is contraindicated in atrial fibrillation associated10

with Wolff-Parkinson-White syndrome. The main advantagedigoxin has over other drugs available to control conductionthrough the AV node, is the fact that it is not a negativeinotrope. Most patients with atrial fibrillation have significantunderlying cardiac disease and often tolerate poorly themyocardial depressant effects of verapamil and propranolol,making digoxin the safest choice. The effects of digoxin areincreased in the presence of hypokalaemia, hypothyroidism,hypomagnesaemia, and hypercalcaemia. Digoxin should notbe given to patients with bradycardia. The maximumtherapeutic effects of digoxin are delayed by 6 to 24 hours afteradministration. The usual initial dose is 10 micrograms per kggiven intravenously over 20 to 30 minutes and the totaldigitalizing dose should be given within 24 hours.1.8.6 AdenosineAdenosine is a very short acting agent used in the treatment ofsupraventricular tachycardia. It is best given in incrementaldoses according to response (usually 6 mg initially and if noresponse, give 12 mg and if necessary followed by 18 mg).Adenosine should be given as a rapid intravenous bolusfollowed by a 20 ml 0.9% saline flush. It should be given withgreat care to asthmatics as it may occasionally induce severebronchospasm in these patients. Adenosine is antagonised bytheophylline and is unlikely to be effective in patients who aretaking this drug.11

1.9 AntihypertensivesSeveral different drugs are available for the management ofhypertensive emergencies.Hydrallazine is a direct acting arteriodilator. It should not beused in patients with ischaemic heart disease who are not beingtreated with a beta-blocker. Side effects include nausea,tachycardia, and headache. Peak effects are not seen for 10 to20 minutes after intravenous injection and it has a duration ofaction of 4 to 8 hours. The usual dose in adults is 10 mgintravenously every 20 minutes to a maximum of 50 mg.Nifedipine is a direct-acting arterial vasodilator. When givenby sublingual route, it has unpredictable effects and canprecipitate myocardial infarction or stroke by excessivelowering of blood pressure. Hence, it should not given by thisroute.1.10 Inotropic AgentsInotropic agents are used in the treatment of cardiogenic anddistributive shock. All should be infused via a large vein.Adrenaline is an alpha- and beta-adrenergic agonist. It causesan increase in cardiac output and heart rate plusvasoconstriction. It is given by infusion into a large vein at arate of 1 to 70 micrograms per minute titrated to effect.12

Dopamine has similar effects to adrenaline but produces moretachycardia at higher doses. It may preferentially enhance renalblood flow at rates less than 5 micrograms per kg per minute.Dobutamine has positive chronotropic and inotropic effectswhich are balanced by a mild degree of vasodilation so thatmyocardial oxygen demand is generally not increased.Dobutamine is generally considered the inotrope of choice inpatients with myocardial ischaemia. The usual dose range is 2to 20 micrograms per kg per minute titrated to effect.1.11 DiureticsFrusemide is a potent loop diuretic used in the treatment offluid overload. Its main side effects are hypokalaemia andfluid depletion. Damage to the inner ear may occur with toorapid intravenous injection. Frusemide is ineffective in theacute treatment of hypertension and should not be used exceptas an adjunct to other more powerful drugs.Intravenous frusemide has an onset of action within 5 minutes,a peak effect at about 30 minutes, and a duration of action of 2hours. Dosage varies according to renal function; most patientswithout renal impairment will have a significant diuresis after40 mg given intravenously. Doses in excess of 250 mg may berequired to diurese patients with severe renal failure.Frusemide should not be given intravenously at a rate fasterthan 40 mg per minute. The absorption of intramuscularfrusemide is unpredictable and this route of administration13

should not be used.1.12 Muscle RelaxantsSuxamethonium is a depolarising muscle relaxant. It is givenas an intravenous bolus and has its maximal effect within 60seconds. The duration of paralysis is usually about 5 minutes.Very rarely, some patients with an atypical plasmacholinesterase enzyme will be paralysed for much longer. Theusual dose is 1 to 1.5 mg per kg in adults and 2 mg per kg inchildren. Suxamethonium is contraindicated in the presence ofhyperkalaemia, lower motor neurone diseases, and between 3days and 2 years after major burns. In the absence of thesecontraindications, suxamethonium is the drug of first choice formuscle relaxation in rapid sequence intubation.Vecuronium is a non-depolarising muscle relaxant. Given asan intravenous bolus it has its onset in about 3 minutes andlasts 20 to 30 minutes. The usual dose is 0.1 mg per kg.1.13 NeurolepticsHaloperidol is the safest neuroleptic to use for sedation. Itmay be given intramuscularly or intravenously. The usualintravenous dose in adults is 2.5 mg repeated every 5 minutesto a maximum of to 10 mg.Chlorpromazine is more likely to cause hypotension thanhaloperidol.14

Diazepam can be used as a sedative for short defined periodsof treatment to avoid addiction.1.14 Anti-asthma DrugsSalbutamol is a beta-2 adrenergic agonist. It is best given inthe inhaled form (either via an inhaler or a nebulizer).Intravenous salbutamol may occasionally be required for verysevere asthma where marked airway obstruction may preventthe inhaled form of the drug from reaching the distal airways.The main side effects of salbutamol are sinus tachycardia,tremor, and anxiety. It can also cause hypokalaemia.Nebulized salbutamol may be given as often as necessary, evencontinuously. The upper dose limit is defined in each patientby the adverse effects of tachyardia and tremor. The usual doseis 5 mg in adults and older children, and 2.5 mg in children lessthan 5 years old. The dose should be diluted up to 2 ml using0.9% saline but may be given without dilution.Intravenous salbutamol is given in a dose of 5 micrograms perkg (up to a maximum of 250 micrograms) over 1 to 2 minutesand repeated once 15 minutes later if necessary.Ipratropium is used in the treatment of asthma and chronicobstructive pulmonary disease (COPD). It has a synergisticeffect with salbutamol. Adverse systemic effects are very rarebut nebulized ipratropium can inadvertently enters the eye andcauses a fixed, dilated pupil. The usual dose in adults is 0.5 mg15

via a nebulizer every 4 to 6 hours. Children 5 years of age orunder should be given 0.25 mg per dose.Corticosteroids are discussed in Section 1.6.Aminophylline is a xanthine derivative that has been used formany years in the treatment of asthma. However, it is a weakbronchodilator and has no additional benefit over optimal dosesof salbutamol. It also has a very narrow therapeutic marginand therefore has little place in the management of acuteasthma. Adverse effects include ventricular tachycardia,seizures, and hypokalaemia. Its use should be restricted tosevere asthma.1.15 Intravenous FluidsNormal (0.9%) saline contains 154 mmol per liter of sodiumchloride. It is essentially isotonic and iso-osmolar, and isdistributed to the extracellular fluid space. It is the fluid offirst choice in the treatment of hypovolaemia. Normal salinecontains too much saline to be used as the sole maintenancefluid, although it may be alternated with 5% dextrose.Dextrose 5% contains 50 g per liter of dextrose. It isdistributed to the total body water space and is thus not suitablefor emergency rehydration. Although it can be used as thesole maintenance fluid in the short term, prolongedadministration of 5% dextrose alone may cause hyponatraemia,especially in children.16

Dextrose 3% with 0.3 saline contains 51 mmol per liter ofsodium chloride and 30 g per liter of dextrose. Its primary useis as a maintenance fluid (with potassium) in children. It maybe suitable for rehydration of patients with mild or moderatedehydration.Hartmann’s solution contains a mixture of ions similar to thatof the extracellular fluid. It may be substituted for 0.9% salineexcept in the presence of hyperkalaemia or alkalosis. Itcontains 140 mmol per liter of sodium, 109 mmol per liter ofchloride, 29 mmol per liter of bicarbonate, 5 mmol per liter ofpotassium, and 2 mmol per liter of calcium.Plasma volume expanding solution (e.g. Haemaccel,Gelofusin): Colloids can be used for patients withhypovolaemic shock in association with crystalloid solutions.1.16 Tetanus ProphylaxisRegular immunization with tetanus toxoid is the best way toprevent death due to tetanus. Children should receive doses oftetanus toxoid at 6, 10 and 14 weeks of age then booster dosesat 6 years. Thereafter, booster doses of tetanus toxoid shouldbe given every 10 years.Patients presenting with a skin wound should be treated asdescribed below. A non-immune patient is one who has neverreceived a full course of tetanus toxoid injections. Tetanus17

prone wounds include puncture wounds, contaminated orinfected wounds and crush wounds.1.16.1 Non-immune patient with tetanus pronewound Give tetanus toxoid 0.5 ml intramuscularly and completecourse (with repeat tetanus toxoid injections at 6 weeksand 6 months),PLUS Give tetanus immune globulin 250 units intramuscularly ata different site than that of the tetanus toxoid injection.1.16.2 Non-immune patient with clean wound Give tetanus toxoid 0.5 ml intramuscularly and completecourse (with repeat tetanus toxoid injections at 6 weeksand 6 months).1.16.3 Immune patient with tetanus prone woundIf more than 5 years since last tetanus toxoid booster THEN Give tetanus toxoid 0.5 ml intramuscularly.1.16.4 Immune patient with clean woundIf more than 10 years since last tetanus toxoid booster THEN18

Give tetanus toxoid 0.5 ml intramuscularly.1.17 Drugs Used in Cardiac ArrestAdrenaline is a powerful endogenous catecholamine. Thepharmacologic doses used in cardiac arrests far exceed theamounts usually produced by the adrenal glands. Adrenalinehas both alpha- and beta-adrenergic agonist effects. Itstimulates myocardial contraction, increases the heart rate, andraises the blood pressure. Its most dangerous adverse effect isinduction of ventricular arrhythmias, an effect which is farmore likely when the myocardium is sensitized tocatecholamines. This occurs with myocardial ischaemia(which adrenaline can also induce by increasing myocardialwork), and with overdoses of drugs such as amphetamines andcocaine. In the setting of a cardiac arrest, the induction ofventricular arrhythmias is obviously not a problem and a largeintravenous bolus doses should be given. However, insituations other than cardiac arrest, such as anaphylaxis orasthma, adrenaline should be used with great care to avoidworsening the patient’s condition. In these circumstances,adrenaline is best given intravenously in small carefully titrateddoses. Also see Section 1.10.The absorption of adrenaline given by the subcutaneous orintramuscular routes is unpredictable especially in shock statesbut administration by these routes can be life-saving in patientsin shock states due to anaphylaxis. In ventricular fibrillation orasystole, adrenaline should be given in doses of 1 mg by19

intravenous bolus. Administration should be by a central line ifalready present or by a large peripheral vein and followed by a20 ml 0.9% saline flush to ensure it rapidly reaches the centralcirculation. If there is no intravenous access then adrenalinecan be given via the endotracheal tube. When given by thisroute it should be diluted in 10 ml of 0.9% saline and the doseshould be 5 times the intravenous dose. There is no role forintracardiac injection of adrenaline (or any other drug).Lignocaine is recommended for the treatment of ventricularfibrillation and ventricular tachycardia. Its effectiveness has notbeen proven but it is unlikely to be harmful. The usual dose is1 mg per kg intravenously given over 1 minute. Lignocainehas a short therapeutic half-life so a successful bolus doseshould be followed by a lignocaine infusion. Lignocaine maybe given via the endotracheal tube if intravenous access isunavailable. Twice the intravenous dose is used and it shouldbe diluted in 10 ml of 0.9% saline. Also see Section 1.8.1.Atropine is used in the treatment of asystole and severebradycardia. It acts to block the effects of the vagus nerve onthe heart. A dose of 3 mg in an adult produces completeatropinization, blocking all the cholinergic receptors. The mainadverse effect of atropine is to produce a sinus tachycardiawhich may be harmful in the presence of ischaemic heartdisease. The usual total dose of atropine used in cardiac arrestis 40 micrograms per kg which may be given as a single bolusor in several divided doses a few minutes apart. Also seeSection 1.3.20

Sodium bicarbonate is used to treat the metabolic acidosisassociated with cardiac arrest. Its effectiveness has not beenproven and it has many potential adverse effects. Mostauthorities recommend that it be given in prolonged cardiacarrests (i.e. those greater than 10 minutes in duration). Itshould be given earlier in the presence of acute renal failure,hyperkalaemia, or tricyclic antidepressant overdose. The usualdose is 1 mmol per kg intravenously over 1 to 2 minutes.21

2 CardiovascularEmergencies2.1 Cardiac Arrest2.1.1 Basic cardiac life support (BCLS)Prompt and effective cardiopulmonary resuscitation (CPR) hasbeen shown to increase survival after cardiac arrest. It shouldbegin as early as possible after the onset of cardiac arrest andcontinued with as little interruption as possible until the patienteither recovers spontaneous circulation or a decision is made tocease the resuscitation efforts.a. Call for helpProper CPR requires at least two people. At least one otherperson is required to obtain the drugs and equipment needed foradvanced cardiac life support.b. Check for responseAssess the patient’s conscious state quickly by shaking thepatient and yelling his or her name. Loss of consciousnessalways accompanies cardiac arrest. Unconscious patients areunable to protect their own airway.22

c. AirwayLook in the mouth for a foreign body or vomitus. Listen forbreath sounds. Noisy breath sounds are a sign of a partlyobstructed airway. The absence of breath sounds may indicatecomplete airway obstruction.Act to protect and maintain the airway. Perform appropriateprocedures including suctioning, head tilt, chin lift, jaw thrust,and insertion of an oral airway. The correct size oral airwaycan be estimated by holding it against the side of the patient’sface – it should reach from the corner of the mouth to the earlobe.d. BreathingLook for movement of the chest wall and listen to the lungs forbreath sounds on both sides of the chest. Asymmetry of breathsounds may be a sign of a pneumothorax.Act by ventilating the patient with a bag and mask. Be sure touse an appropriate size face mask that fits the patient’s face.Mouth to mouth ventilation should be performed if a bag andmask are unavailable.e. CirculationFeel for the carotid or femoral pulse and listen for heart sounds.(The brachial pulse is often the easier to feel in neonates, ratherthan the carotid or femoral). If there is no palpable pulse, act23

y starting external cardiac massage. Cardiac massage shouldbe performed on the lower 1/2 of the sternum, depressing itabout 5 cm in adults and older children. In young children andbabies, it should be depressed about 1/4 of the distancebetween the front and the back of the chest. The rate should be80 per minute in adults and 100 per minute in children andbabies. The ratio of ventilations to compressions depends onthe number of persons doing CPR and is as follows:• If one person, 2:30 in children and ??? in adults• If two persons, 2:15 in children and ??? in adultsStart advanced cardiac life support as soon as possible.2.1.2 Advanced cardiac life support (ACLS)Cardiac arrest most commonly occurs due to life-threateningarrhythmias. The first step in ACLS is to determine what thecardiac rhythm is by attaching a cardiac monitor. Cardiacarrest rhythms can be divided into three basic types:• “Shockable” rhythm• Pulseless ventricular tachycardia (VT)• Ventricular fibrillation (VF)• “Non-shockable” rhythm• Asystole or severe bradycardia• Pulseless ventricular activity.24

a. Pulseless ventricular tachycardia orventricular fibrillation (VF)Ventricular tachycardia without an adequate cardiac outputshould be treated as for ventricular fibrillation. The mostimportant feature of the treatment of these arrhythmias isprompt defibrillation. Defibrillation is the only treatment thathas been definitely shown to increase survival after cardiacarrest – it should be performed as early as possible.The primary drug in the treatment of VF is adrenaline – allother drugs are of secondary importance.• Provide basic cardiac life support as described above.• Defibrillate with 360 joules (first shock) once only.• Immediately continue CPR for 2 minutes continuously.• During CPR, establish intravenous access (if not yetavailable) and secure airway and ventilate with 100%oxygen.• Check heart rhythm after 2 minutes of CPR.If no response:• Defibrillate again (second shock) with 360 joules andresume CPR immediately and continue for 2 minutes.• Check heart rhythm.If still no response:25

• Give adrenaline 1 mg bolus intravenously (1 ml of 1:1,000or 10 ml of 1:10,000) and defibrillate (third shock) with360 joules, followed by CPR for 2 minutes.• Check heart rhythm.NOTE: Adrenaline dose should be followed by a 20 mlnormal saline flush. Adrenaline may also be given down theendotracheal tube – the dose is 5 times the intravenous doseand it should be diluted in 10 ml of normal saline.If still no response:• Give amiodarone 300 mg slow bolus intravenously (ifavailable),ORLignocaine 2%, 100 mg bolus intravenously, anddefibrillate (fourth shock) with 360 joules, followed byCPR for 2 minutes.• Check heart rhythm.If still no response:• Give adrenaline 1 mg bolus intravenously (1 ml of 1:1,000or 10 ml of 1:10,000) and defibrillate (fifth shock) with360 joules, followed by CPR for 2 minutes.26

• Continue defibrillation and CPR for 2 minutes, givingadrenaline every alternate cycle.Sodium bicarbonate is generally not indicated unless cause ofarrest is secondary to hyperkalaemia or tricyclic overdose.NOTES:• If there is no spontaneous circulation 20 minutes aftercardiac arrest then the chance of recovery is essentiallyzero and resuscitation should usually be ceased.• If sinus rhythm is restored, check for pulse and bloodpressure. The patient may require an adrenaline infusionto maintain blood pressure. Lignocaine or amiodaroneinfusion should be continued (refer to Annex).In children: Defibrillate at 2 joules per kg then 4 joules per kg. Give adrenaline 10 micrograms per kg (0.1 ml per kg of 1:10, 000 up to 1 ml).Ventricular tachyarrhythmias in specialcircumstancesOther drugs may be indicated in some specialcircumstances:Digoxin Toxicity (see Section 5.2.14) – Ventricular27

tachycardia in the presence of digoxin toxicity mayrespond to phenytoin and magnesium sulphate. Ifdefibrillation is necessary then 25 joules may be all that isrequired. Higher defibrillation energies may induceventricular fibrillation.Theophylline Toxicity (see Section 5.2.16) –Administration of intravenous propranolol may be helpfulfor ventricular tachyarrhythmias.b. Asystole or severe bradycardiaAsystole has a very poor survival rate compared to VF. It iswise to make sure that the rhythm is indeed asystole byinspecting more than one lead on the ECG monitor. Veryoccasionally, VF may look like asystole in one of the ECGleads.• Provide basic cardiac life support as described above.• Obtain intravenous access.• Secure airway and continue to ventilate with maximumoxygen available.• Give adrenaline 1 mg intravenous bolus (1ml of 1:1, 000or 10 ml of 1:10 ,000 ).• Continue external cardiac massage.If no response:• Give atropine 3 mg intravenous bolus.• Continue external cardiac massage.If no response:28

• Give adrenaline 5 mg intravenous bolus.• Continue external cardiac massage.• Further doses of adrenaline 1 mg intravenously may begiven at 3- to 5-minute intervals until return ofspontaneous circulation or cessation of resuscitationefforts.NOTES:In children Give adrenaline 10 micrograms per kg ( 0.1 ml per kg of1: 10,000 up to 1 ml) and repeat as necessary every 5minutes. Give atropine 50 micrograms per kg.If there is no spontaneous circulation 20 minutes after cardiacarrest then the chance of recovery is essentially zero andresuscitation should usually be ceased.c. Pulseless ventricular activity (formerly calledelectromechanical dissociation (EMD)This term refers to patients who have a cardiac rhythm otherthan VF, VT, or asystole but without a detectable cardiacoutput. Most cases are due to severe and irreversible cardiacmuscle dysfunction but occasionally pulseless ventricularactivity may be due to a treatable cause.29

Treatment is as for ventricular asystole with the addition of theneed to exclude potentially reversible causes (“4Hs and 4Ts”)such as:• hypoxia• hypovolemia, severe• hypothermia or hyperthermia• hypokalemia or hyperkalemia and metabolic acidosis• cardiac tamponade• tension pneumothorax• toxins, poisons, drugs• thrombosis – pulmonary or coronary.Tension pneumothoraxInsert a wide-bore intravenous cannula in the secondintercostal space in the midclavicular line on the side ofthe pneumothorax.Hypovolaemia Administer Haemaccel 10 m per kg intravenous bolusstat.Severe hyperkalaemia or acidosis Give 0.1 ml per kg of 10% calcium chloride (to amaximum dose of 10 ml) intravenous bolus and repeatin 5 minute, if necessary,30

PLUS Give 8.4% sodium bicarbonate 1 mmol per kgintravenous bolus.Calcium channel blocker overdose orhypocalcaemia Give 0.1 ml per kg of 10% calcium chloride (to amaximum of 10 ml) intravenous bolus and repeat in 5minutes, if necessary.Beta-adrenergic antagonist overdose (see Section5.2.7) Give glucagon 5 mg intravenous bolus.NOTE: This is not available in the EDL (Essential DrugList).• Obtain intravenous access.• Secure airway and continue to ventilate with maximumoxygen available.• Give adrenaline 1 mg intravenous bolus.• Continue external cardiac massage.• Give adrenaline 5 mg intravenous bolus.• Continue external cardiac massage.31

2.1.3 IntubationEndotracheal intubation should be attempted as soon aspossible during cardiopulmonary resuscitation to ensureadequate ventilation.2.2 Cardiogenic ShockCardiogenic shock is defined as a state where the cardiacoutput is inadequate to maintain tissue perfusion. It is usuallycharacterised by hypotension, compensatory peripheralvasoconstriction, and signs of congestive cardiac failure. It isvery important to distinguish cardiogenic shock fromhypovolaemic shock and distributive shock (due to anaphylaxisor sepsis).Cardiogenic shock has many different causes, the usual beingacute myocardial infarction. Treatment of the underlyingcause, whenever possible, is essential. Administration ofinotropic agents should be viewed only as a temporary measurewhile the underlying cause is reversed. Close monitoring in anintensive care unit is highly desirable. The prognosis ofcardiogenic shock is dismal and most patients will not recoverdespite the following therapy.2.2.1 Maintain airway and breathingThe usual maneuvers to maintain an adequate airway andadequate ventilation, up to and including endotracheal32

intubation should be used. All patients should at least receivehigh flow oxygen via face mask. Give oxygen to maintain arterial oxygen saturationgreater than 95%.2.2.2 Optimise intravascular volumeInsertion of a central venous line allows accurate measurementof central venous pressures (CVP) and also makesadministration of inotropic agents safer. If CVP line is notavailable, examination of neck veins must be used. Correctanaemia with administration of blood or otherwise use bolusesof normal saline to achieve an optimal CVP (5 to 10 cm water).Note that patients with right ventricular infarction usuallyrequire a much higher central venous filling pressure (e.g. 20cm water) than other patients. Give 0.9% saline boluses of 100 ml intravenously to obtainan optimal central venous filling pressure.2.2.3 Inotropic agentsThe initial agent of choice in cardiogenic shock is dobutamine,if available. Dopamine is a suitable alternative.In ADULTS: Give dobutamine 2 micrograms per kg per minute byintravenous infusion and increase rate by 1 to 233

micrograms per kg per minute every 5 minutes to amaximum of 20 micrograms per kg per minute;OR Give dopamine 2 micrograms per kg per minute byintravenous infusion and increase to 20 micrograms per kgper minute, if necessary.In CHILDREN: Give dobutamine 2 micrograms per kg per minute byintravenous infusion and increase rate by 1 to 2micrograms per kg per minute every 5 minutes accordingto response to a maximum of 20 micrograms per kg perminute;OR Give dopamine 2 micrograms per kg per minute byintravenous infusion and increase rate by 1 microgram perkg per minute every 5 minutes according to response to amaximum of 20 micrograms per kg per minute.NOTE: Ideally, inotropic agents should be infused via acentral venous line. Otherwise, a large peripheral vein (such asthe femoral vein or the cubital veins) should be used. In somesituations, a combination of dopamine and dobutamine can bemore effective than either agent alone.34

2.3 Unstable AnginaThis coronary syndrome is characterized by anginal pain whichis severe, of recent onset, or which has recently becomeabruptly worse. Angina occurring at rest or following recentmyocardial infarction is also classified as unstable angina.There is evidence that the reason for unstable angina is asudden change in a previously stable plaque within anatheromatous coronary artery. Rupture of the endotheliumover and around the plaque leads to vasoconstriction, plateletadhesion, and an inflammatory response. If the vessel becomescompletely occluded, a myocardial infarct will result.However, commonly, occlusion is not complete and the areaaround the plaque settles down over a period of a few weeks.All patients diagnosed to be suffering from unstable anginashould be referred for admission preferably to the CoronaryCare Unit (CCU).The most important distinction to make is between unstableangina and an acute myocardial infarction. The factorsfavouring an acute myocardial infarction include pain of morethan 15 to 20 minutes duration; pain not responsive to nitratesor requiring narcotics; and systemic features such as pallor,sweating, vomiting, and hypotension. If any or all of these arepresent, refer immediately to hospital. An electrocardiogram(ECG) is critically important in making the diagnosis.The aim of treatment in unstable angina is to relieve the painand to modify the environment around the “active” plaque to35

educe the likelihood of coronary artery occlusion andsubsequent myocardial infarction. However, it should be bornein mind that chest pain might be secondary to other seriousconditions like acute myocardial infarction, pericarditis, aorticdissection, and pulmonary embolism.For initial treatment: Oxygen therapy. Aspirin 150 to 300 mg orally stat,AND Morphine 2.5 to 5 mg intravenously as needed,AND Atenolol 50 to 100 mg orally daily,OR Propranolol 40 to 80 mg orally two to three times daily.If pain still persists, in addition, heparin should be given asfollows: Heparin 5,000 units intravenous bolus dose followed by1,000 units per hour by intravenous infusion.The infusion rate should be adjusted to keep the PTTK (partialthromboplastin time with kaolin) between 60 and 85 seconds.36

The PTTK should be measured 6-hourly until stable, then dailythereafter.Heparin will normally be required for at least 3 days andpossibly longer depending on clinical response.If pain persists and if the patient’s hemodynamic status allows,ADD: Nifedipine SR 20 to 40 mg orally twice daily,AND, if required, ADD Isosorbide dinitrate 10 to 40 mg orally three times daily.If symptoms persist despite all of the above treatment,cardiological intervention, if available, is required with a viewto further investigation and revascularization.2.4 Acute Myocardial InfarctionComplete occlusion of a coronary artery leads to the death ofthe cardiac muscle it supplies. Occlusion of a large, proximalvessel may cause myocardial ischaemia of such an extent thatthe patient dies rapidly of pump failure. Alternatively, aventricular arrhythmia (tachycardia, fibrillation) may reducecardiac output to such a drastic extent that, if the abnormalrhythm cannot be reversed, death is most likely.37

Severity of pain by itself is a poor indicator of the extent ofmyocardial damage especially in a diabetic patient. Poorcerebral function, peripheral circulatory signs such as pallor,sweating, and hypotension combined with extensive ECGchanges with or without arrhythmias point to a large infarct.The aims of immediate management are to:• relieve pain• achieve coronary reperfusion and minimize infarct size• prevent and treat heart failure and shock• allay the patient’s anxietyAll patients with suspected myocardial infarction should beadmitted to hospital and preferably to a unit where cardiacmonitoring can be performed.2.4.1 Immediate management Aspirin 300 mg chewed or dissolved before swallowing. Oxygen 4 to 6 liters per minute by mask. Morphine 2.5 to 5 mg intravenously with repeat doses asnecessary for pain relief,AND Glyceryl trinitrate 600 micrograms sublingually with arepeat dose in 5 minutes if no response.It should not be given in hypotension and if right ventricularinfarction is suspected.38

Unless the patient is very anxious, routine use of a sedativedrug (e.g. diazepam) is not recommended.2.4.2 Thrombolytic therapyThe indications for thrombolytic therapy includes chest painthat has developed within the previous 12 hours with either STsegment elevation myocardial infarction (STEMI) ordevelopment of new left bundle branch block (LBBB).StreptokinaseAdminister streptokinase (STK) 1.5 millioninternational units (IU) by intravenous infusion over30 to 60 minutes. If blood pressure falls as a result ofthe infusion, reduce the rate or stop briefly and restartat half the previous rate.Streptokinase induces antibody formation that makesit unsuitable for use in subsequent episodes ofcoronary occlusion. It may also produce allergicsymptoms (i.e. bronchospasm, angio-oedema,urticaria, flushing, and musculoskeletal pain).The contraindications to thrombolytic therapy areshown in Table 1.Patients most likely to benefit from thrombolytictreatment are those presenting early with large anteriorinfarcts especially if complicated by heart failure.39

Those presenting after 24 hours have less chance ofbenefit and increased risk of cardiac rupture.For mild or moderate allergic reactions tostreptokinase: Promethazine 25 mg intravenously,AND / OR Hydrocortisone 100 mg intravenously.Severe allergic reactions should be treated as foranaphylaxis. Give Adrenaline 1 in 1,000 solution, 0.5 to 1 ml ( 0.5 to1 mg) intravenously over 5 minutes.If response is poor, increase dose to: Adrenaline 1 in 1,000 solution 2 to 5 ml (2 to 5mg) intravenously over 5 minute,AND ADD Promethazine 25 mg intravenously,OR Hydrocortisone 100 mg intravenously.40

NOTE: Refer to Cardiovascular Guidelines for details on thesubsequent management of unstable angina and acutemyocardial infarction.2.5 Cardiac ArrhythmiasCardiac arrhythmias range from trivial ectopic beats to the lifethreateningventricular fibrillation. Whether or not anarrhythmia requires intervention depends largely on its capacityto make a significant impact on cardiac output.In a patient whose myocardial function is already impaired(e.g. by a large infarct) a change from normal sinus rhythm toatrial fibrillation with an increased ventricular rate of 140 beatsper minute may be sufficient to cause heart failure. Bycontrast, a young person with a normal myocardium maysustain a supraventricular tachycardia at the same rate for dayswithout any evidence of cardiac decompensation.The urgency for intervention and the nature of that interventionare dictated equally by the situation in which the arrhythmiaoccurs and by the nature of the arrhythmia itself.Most arrhythmias are benign and injudicious use ofantiarrhythmic drugs can be harmful as many of them areproarrhythmic in their own right.41

Table 1. Contraindications to thrombolytic therapyAbsolute contraindicationsActive internal bleedingRecent surgery, biopsy ortraumaPrior cardiopulmonaryresuscitationKnown bleeding disease(haemophilia, plateletdisorders)Ischemic stroke within 6monthsNeurosurgery within 6 monthsA previous intracranial bleedSevere uncontrolledhypertension (a bloodpressure greater than 180/110mm Hg duringpresentation)Aortic dissectionComaOesophageal varicesRelative contraindicationsPrevious peptic ulcer diseaseWarfarin therapyLiver diseasePrevious streptokinasetherapy within the lastfour yearsPrevious hypersensitivity tostreptokinaseHeavy perivaginal bleedingDiabetic proliferativeretinopathyPregnancy42

2.5.1 Tachyarrhythmiasa. Atrial tachyarrhythmiasi. Sinus tachycardiaThis implies a persistent heart rate over 100 perminute in a resting patient.It usually has an underlying cause such as anxiety,thyroid overactivity, or systemic illness. The firstapproach should be to identify and treat the underlyingcause.If no obvious underlying cause is apparent,treatment is generally not needed.ii.Atrial premature complexesTreatment is seldom required.symptomatic,If patient is Atenolol 25 to 100 mg orally daily,OR Propranolol 40 to 80 mg orally two to three timesdaily.43

iii.Paroxysmal supraventricular tachycardia(PSVT)This occurs intermittently and sometimes can beconverted to sinus rhythm by carotid sinus massage,by the Valsalva manoeuvre, or by holding ice coldwater in the mouth. If these are ineffective, Verapamil 5 mg intravenously slowly, repeat ifneeded up to 15 mg;OR Adenosine 6 mg bolus intravenously over 5 to 10seconds, if unsuccessful,followed by 12 mg intravenously 2 minutes later,and if needed, 18 mg intravenously thereafter.Adenosine can produce chest pain and large falls inblood pressure. However, the half-life of the drug isshort and recovery will occur within one minutenormally without intervention. If the symptomspersist, aminophylline intravenously can be used.If above drugs are not available, Digoxin 0.25 to 0.50 mg orally stat,repeat same dose orally 6 hours later,followed by 0.25 mg orally 6 hours after thesecond dose,44

followed by 0.25 mg orally 6 hours after the thirddose, andcontinue at 0.25 orally mg daily.If rapid control is needed, digoxin may be givenintravenously (see below under section on atrialfibrillation).The maintenance digoxin dose should be adjusteddepending on the patient’s renal function and serumpotassium level.Verapamil must never be given to a patient with awide-complex undiagnosed tachycardia – QRS >0.12 seconds. If there is any possibility that therhythm is a ventricular tachycardia, either useadenosine or treat as for ventricular tachycardia.Once arrhythmia has been stabilized, prophylaxisagainst further attacks of PSVT, if frequent, must beinitiated. Drugs that can be used for prophylaxisinclude digoxin, beta-blockers, calcium channelblockers, and amiodarone (in difficult cases).iv.Atrial flutter and fibrillationAtrial flutter usually presents with a 2:1atrioventricular block and a regular rate of around 150beats per minute. Atrial fibrillation presents with asimilar rate which is however quite irregular. Theaims of treatment are discussed below.45

• Control ventricular rateThis is only required if the ventricular rate is >100 perminute. The urgency to control the rate depends onthe pre-existing ventricular rate. Digitalization:Digoxin 0.25 to 0.50 mg orally stat,repeat same dose orally 6 hours later,followed by 0.25 mg orally 6 hours after thesecond dose,followed by 0.25 mg orally 6 hours after the thirddose, andcontinue at 0.25 orally mg daily.The intravenous route is rarely necessary because oraldigititalization is just as effective. However, if rapiddigitalization is needed, digoxin may be givenintravenously. The total loading dosage is 0.5 to 1.5mg. A loading dose of 0.5 mg in 20 ml of normalsaline is given as an intravenous infusion for 20minutes. The remaining dose is also givenintravenously over 20 minutes at intervals of 4 to 6hours depending on the response over a period of 24hours. The total digitalizing dose will need to bereduced if the patient has had digoxin in the preceding2 weeks.46

OR Verapamil 5 mg intravenously up to 15 mg withcareful monitoring of pulse and blood pressure.For long-term control, the drugs that can be used aresimilar to that mentioned under the section on PSVT.• Treatment of underlying causeWhenever possible, the underlying cause should beidentified and treated (e.g. hypokalaemia,thyrotoxicosis).• Reversal to sinus rhythmFor atrial fibrillation of recent onset, considerationshould be given to convert it to sinus rhythm byelectrocardioversion. Medical therapy withamiodarone or sotalol might be effective. In chronicAF, recent evidence suggests that rate control is justas effective as rhythm control.• Anticoagulant therapyUnless contraindicated and impractical (i.e. poorpatient compliance, difficulty in monitoring),anticoagulant therapy should be considered in everypatient with chronic AF to prevent thromboembolicevent. If warfarin cannot be used for one reason oranother, aspirin can be used as alternative but is not as47

effective as warfarin. The risk of thromboembolismincreases in patients with previous thromboembolism,mitral valve disease, heart failure, hypertension, andin older patients – especially women over the age of75 years.b. Ventricular arrhythmiasi. Premature ventricular ectopics includingbigeminyThese are benign unless patients have underlying heartdisease. If no obvious cause is found, the followingmeasures are advisable:• reduction of coffee and tea intake• cessation of smoking• reduction alcohol intake.Drug treatment is not normally required but insymptomatic cases beta-blockade may be of value. Atenolol 25 to 100 mg orally daily,OR Propranolol 40 to 80 mg orally two to three timesdaily.48

ii.Ventricular tachycardia (VT)• Non-sustained ventricular tachycardiaIn hospitals where ECG monitoring is possible, treatonly prolonged episodes that cause cardiovascularhaemodynamic instability. Lignocaine 2%, 50 to 100 mg intravenously over1 to 2 minute, followed by 4 mg per minuteintravenous infusion for a maximum of one hour,then 1 to 2 mg per minute by intravenous infusionfor 24 hours (see Appendix).If patient is unresponsive or if lignocaine iscontraindicated use: Amiodarone 5 mg per kg intravenously(preferably through a central venous line) over 1to 2 hours, followed by 10 to 15 mg per kg infusedover a 24- hour period (see Appendix).• Sustained ventricular tachycardia- With haemodynamic stabilityTreatment is the same as for non-sustainedventricular tachycardia.- With haemodynamic instability (“pulselessVT”) – Refer to Section 2.1.49

iii.Ventricular fibrillation – Refer to Section2.1.iv. Ventricular asystole – Refer to Section 2.1.v. Torsades de pointesThis is a rare, polymorphic ventricular tachycardia inwhich the QRS axis is constantly shifting (turning,“torsade”). Patients usually have a prolonged QTc(greater than 0.45 seconds) on the ECG. The rhythmis particularly prone to occur as a result of drugtherapy including treatment with tricyclicantidepressants, phenothiazines, erythromycin, andketoconazole. Any drug suspected of causing thearrhythmia should be stopped immediately.Patients should be managed in hospital with ECGmonitoring. No consensus exists about the mosteffective treatment. Lignocaine can be effective. Lignocaine 2%, 75 to 100 mg intravenously over1-2 minutes, followed by 4 mg per minute for amaximum of one hour. Maintenance infusionthereafter of 1 to 2 mg per minute by intravenousinfusion (see Appendix).Alternatively,50

Magnesium sulphate 50%, 2 grams intravenouslyover 10 to 15 minutes, followed, if necessary, by0.5 to 0.75 gram per hour by intravenous infusionfor 12 to 24 hours.DO NOT use amiodarone to treat this arrhythmiaas it may provoke it.2.5.2 Bradyarrhythmiasa. Sinus bradycardiaTreat only if symptomatic. Exclude hypothyroidism, pituitaryfailure, and drugs (e.g. beta-blockers, digoxin, and verapamil).If intervention is required: Atropine 0.6 to 1.8 mg intravenously and repeat as needed.b. Atrioventricular blockDrugs (digoxin, beta-blockers, or verapamil) may be the causeand should be withheld if this appears to be the case.i. First degree AV blockThere is prolonged PR interval on ECG. This requiresno treatment.51

ii.Second degree AV blockThere are two types.• Wenckebach phenomenon (Mobitz type I)In this type of AV block, there is successiveprolongation of the PR interval followed by a droppedbeat and the whole cycle repeats.• Mobitz type IIThere is a fixed ratio between the atrial andventricular contractions in this type of arrhythmia, e.g.2:1 or 3:1.Generally, both types of AV block do not requiretreatment. Rarely, pacing may be required in Mobitztype II AV block.iii.Third degree heart blockThis may be an acute and potentially spontaneouslyreversible complication of, for example, an acuteanterior or inferior myocardial infarction. In centerswhere cardiac pacing is possible, this is the treatmentof choice.If pacing is not available give Isoprenaline 20 micrograms intravenously,52

epeat according to clinical response, andfollow with an infusion of 1 to 4 micrograms perminute, oroccasionally higher in patients who have been onbeta-blockers (see Appendix).There is anecdotal evidence for the efficacy ofephedrine, salbutamol, and theophylline inmaintaining response if the block has responded toisoprenaline.The treatment of choice for chronic heart block ispermanent cardiac pacing.iv.Sinoatrial block and sick sinus syndromeThese conditions require pacemaker therapy ifpersistent. However, this therapeutic option iscurrently not available in Fiji.2.6 Acute Pulmonary OedemaAcute pulmonary oedema is a medical emergency that requiresprompt treatment. Oxygen, morphine, vasodilators, anddiuretics should be used. If the patient becomes hypotensive(systolic blood pressure

2.6.1 Maintain airway and give oxygenGive high flow oxygen via a face mask. Some patients withsevere pulmonary oedema may require intubation andmechanical ventilation. The use of continuous positive airwaypressure (CPAP) via mask is very useful if available.2.6.2 PositioningSit the patient upright. This reduces the intrathoracic bloodvolume and improves ventilation of the lungs.2.6.3 DiureticsIntravenous frusemide has a beneficial vasodilatory action aswell as being a powerful diuretic: Give frusemide 40 mg intravenous bolus.NOTE: Patients with renal impairment or those who arealready on frusemide therapy may require larger doses offrusemide (up to 250 mg). It is best to titrate repeat dosesaccording to the patient’s response. If the urine output isinadequate 30 minutes after the first dose then give a furtherdose of 80 mg intravenously. Doses greater than 40 mg shouldbe given slowly over 5 to 10 minutes to avoid damage to theinner ear.54

2.6.4 MorphineNarcotics reduce anxiety and dyspnea and may also causepulmonary vasodilation. Give morphine 2.5 to 5 mg intravenously every 5 minutesto a maximum of 15 mg.NOTE: Use the lower dose of morphine in the elderly andthose patients with a lower body weight.2.6.5 BronchodilatorsFluid in the airways often causes bronchospasm which worsensthe effect of pulmonary oedema. If there is any wheeze orother evidence of bronchospasm then Give salbutamol 5 mg via nebulizer (using oxygen) andrepeat in 30 minutes if necessary.2.6.6 VasodilatorsGlyceryl trinitrate and isosorbide dinitrate cause vasodilationand may also improve myocardial blood supply. Give glyceryl trinitrate tabs 600 micrograms sublinguallyand repeat every 15 minute, if necessary, ensuring that theblood pressure is maintained.55

NOTE: Glyceryl trinitrate should not be given if the patient isin cardiogenic shock without the concomitant administration ofdopamine or dobutamine.2.6.7 InotropesFailure to respond to the above treatment may require additionof dobutamine or dopamine as for cardiogenic shock. Mostpatients needing inotropes will also need intubation andmechanical ventilation. Persistent hypoxia (oxygen saturationless than 90%) despite treatment is an indication for intubation.2.7 Hypertensive EmergencyThis is seldom needed but may be required in hypertensiveencephalopathy, acute hypertensive heart failure, dissectinganeurysm, and phaeochromocytoma. Patients with theseconditions should be admitted to the hospital and monitored.The aim is to reduce blood pressure within 60 to 90 minutes.While the blood pressure may respond to oral agents (asabove), initial parenteral treatment may be needed. Hydrallazine 5 mg bolus intravenously over 5 to 10minutes and repeated every 20 minutes up to a maximumof 20 mg, followed by intravenous infusion of hydrallazine(see Appendix);OR56

Labetalol (100 mg per 20 ml); initial dose of 20 to 40 mggiven intravenously over 1 to 2 minutes, and repeated atintervals of 5 to 10 minutes until 200 mg have been given.Alternatively, labetalol may be given as a continuousintravenous infusion at a rate of 2 mg per minute (seeAppendix).After initial stabilization, the patient should be changed to oraltreatment for maintenance.The practice of opening a nifedipine 10 mg capsule andgiving it sublingually is not supported as emergencytreatment. It delivers an uncertain dose and most of the effectoccurs as a result of absorption of the swallowed drug. Onoccasions in older patients unexpected rapid falls in bloodpressure have resulted in stroke or myocardial infarction.In Fiji, nifedipine 10 mg capsule is restricted to obstetric andpaediatric practice.Please note that in some situations, urgent reduction withintravenous drugs over a short period of time is notrecommended (e.g. severe, uncomplicated essentialhypertension; severe hypertension postoperatively in a patientsuffering from pain; severe asthma). In such situations, oralantihypertensive drugs can be used and blood pressurereduction can be achieved in 48 to 72 hours.57

3 RespiratoryEmergencies3.1 AsthmaAsthma is a common respiratory disease in both adults andchildren. Severity is estimated by clinical assessment, and ifavailable, by measurement of peak expiratory flow rate and bypulse oximetry. Patients with severe asthma should beconsidered for management in an intensive care unit and mayoccasionally require intubation and mechanical ventilation.3.1.1 Treatment in adultsa. OxygenAll patients with moderate or severe asthma should be givenoxygen. Give oxygen by face mask, if required, to maintain oxygensaturation ≥ 92%.b. Beta-adrenergic agonistsUse beta-adrenergic agonists to reverse bronchospasm. In verysevere asthma where nebulized salbutamol might not reach theperipheral bronchi, intravenous salbutamol may also be58

equired. Give salbutamol 5 mg by nebulizer with oxygen (≥ 8 litersper minute) and repeat every 30 minutes as necessary(may give continuously in severe asthma),OR Give salbutamol by puffer ideally using spacer (up to 50puffs) if nebulizers are not available, if required;PLUS if very severe Give salbutamol 5 micrograms per kg intravenously (to amaximum of 250 micrograms) over one minute thencommence an infusion at 5 micrograms per kg per hour.NOTE: Continuous nebulized salbutamol is probably aseffective as intravenous salbutamol.c. AnticholinergicsThese agents have a synergistic effect with beta-adrenergicagonists. In severe asthma the addition of ipratropium may bebeneficial. Give ipratropium bromide 250 to 500 micrograms bynebulizer and repeat every 4 hours if necessary.59

d. CorticosteroidsSteroids reduce inflammation of the airways. Their effects aredelayed for at least 4 hours but they are important to preventrelapse. Oral steroids are as effective as those givenparenterally in most patients. Give hydrocortisone 200 mg intravenously stat then 100mg intravenously 6-hourly,OR Give prednisolone 40 mg orally daily.e. Other drugsAminophylline provides no additional benefit to optimal dosesof beta-adrenergic agonists. It has a number of undesirableside effects including seizures, ventricular tachycardia,hypokalaemia, and vomiting. Routine use in asthma is notrecommended. However, it may be of benefit in patients withsevere asthma who require hospitalization. A loading dose isgiven to patients who are not taking oral theophylline. Give aminophylline 5 mg per kg (to a maximum of 250 mg)intravenously over 5 minutes followed by an infusion at adose of 0.6 to 0.9 mg per kg per minute.Adrenaline does not appear to have any advantage oversalbutamol. It may be used as a last resort or when intravenous60

access is not available: Give 1:1,000 adrenaline 0.5 to 1 mg intramuscularly orsubcutaneously.NOTE: Adrenaline may be given down the endotracheal tube –the dose is 5 times the intravenous dose and it should be dilutedin 10 ml of normal saline.3.1.2 Treatment in childrena. Oxygen Give oxygen by face mask or by nasal prongs as needed.b. Beta-adrenergic agonistsUse beta-adrenergic agonists to reverse bronchospasm. In verysevere asthma intravenous salbutamol may be useful inaddition to nebulized. Give salbutamol 2.5 mg by nebulizer with 6 to 8 liters ofoxygen per minute to children 5 years of age or under, orgive 5 mg by nebulizer to children over 5 years and repeatevery 30 minutes, if necessary, for at least three times, andif no response, give continuously;PLUS, if very severe,61

Give salbutamol 5 micrograms per kg intravenously (to amaximum of 250 micrograms) over one minute.NOTE: Intravenous salbutamol may be more effective thancontinuous nebulization in young children with severe asthma.c. AnticholinergicsThese agents have a synergistic effect with beta-adrenergicagonists. Give ipratropium bromide 250 micrograms nebulizerevery 20 minutes for three doses and then 2- to 4-hourly.d. CorticosteroidsSteroids reduce inflammation of the airways. Their effects aredelayed for at least 4 hours but they are important to preventrelapse. Oral steroids are as effective as those givenparenterally in most patients. Give hydrocortisone 2 to 4 mg per kg intravenously to amaximum of 200 mg then 6- hourly,OR Give prednisolone 1 to 2 mg per kg orally to a maximumof 60 mg daily.62

e. Other drugsAminophylline provides no additional benefit to optimal dosesof beta-adrenergic agonists. It has a number of undesirableside effects including seizures, ventricular tachycardia,hypokalaemia, and vomiting. Routine use in asthma is notrecommended. However, it may be of benefit in patients withsevere asthma or whenever salbutamol or hydrocortisone is notavailable.A loading dose is given to patients who are not taking oraltheophylline. Give aminophylline 5 mg per kg (to a maximum of 250 mg)intravenously over 5 minutes.Adrenaline does not appear to have any advantage oversalbutamol. It may be used in severe asthma as a last resort orwhen intravenous access is not available. Give 1:1,000 adrenaline 0.1 ml per kg intramuscularly orsubcutaneously to a maximum of 0.5 ml.3.2 Exacerbation of Chronic ObstructivePulmonary DiseaseExacerbation of chronic obstructive pulmonary disease(COPD) is a common problem in emergency medicine. Theresponse of COPD to treatment is generally slower than that of63

asthma and most patients require admission.3.2.1 OxygenIt is essential that oxygen be given to maintain oxygensaturation greater than 92%. Although administration ofoxygen can cause an elevation in arterial carbon dioxide levelsin a few patients, this is far less of a problem than hypoxiaitself. For mildly hypoxic patients, oxygen via an intranasalcatheter will be sufficient while those with more severehypoxia may require oxygen via a face mask. Use the lowestflow rate necessary to maintain an adequate arterial oxygensaturation. Where carbon dioxide retention is consideredlikely, monitor arterial blood gases (ABGs).CAUTION: In patients with carbon dioxide retention, oxygensaturation should be maintained between 90 to 92%.3.2.1 BronchodilatorsSalbutamol and ipratropium have a synergistic action. Give salbutamol 5 mg via nebulizer every 2 to 4 hours asrequired,PLUS Give ipratropium bromide 250 to 500 micrograms vianebulizer every 4 hours.64

3.2.2 CorticosteroidsOral and parenteral routes are equally effective except in thesickest patients. Give hydrocortisone 200 mg intravenously stat then 100mg intravenously 6-hourly,OR Give prednisolone 40 mg orally daily.3.2.3 AntibioticsAntibiotics should be given when infection is the underlyingcause of the exacerbation (as suggested by fever, and/orincreased sputum volume and purulence).NOTE: More serious infections may require intravenousantibiotics. Give amoxycillin 500 mg orally 8-hourly,OR, if penicillin sensitive, Give erythromycin 500 mg orally 6-hourly.3.3 CroupCroup is a viral infection of the upper airway which affects65

children from the ages of 6 months to 3 years. It ischaracterized by fever, a harsh cough, a hoarse voice, andstridor. Children who have stridor while at rest or who havesigns of respiratory distress (i.e. suprasternal retraction,tachypnea, restlessness) should be admitted. Pulse oximetry isuseful – an oxygen saturation of 93% or less while breathingair is also an indication for admission. Most cases of crouphowever are mild and self-limited.3.3.1 Mild croupThese patients will have stridor only with exertion or cryingand no signs of respiratory distress. Avoid exposure to cold air.Give paracetamol for fever. Give paracetamol 20 mg per kg orally 6-hourly asrequired.3.3.2 Moderate croupThese patients will have stridor at rest and some signs ofrespiratory distress but oxygen saturation should be greaterthan 90% on air. Give oxygen to maintain an oxygen saturation greaterthan 93%;PLUS Give dexamethasone 0.6 mg per kg intramuscularly as a66

single dose.3.3.3 Severe croupThese patients will have signs of marked respiratory distressplus hypoxia or cyanosis. Admission to an intensive care unitis desirable and intubation may be necessary. Give oxygen to maintain an oxygen saturation greaterthan 92%;PLUS Give dexamethasone 0.6 mg per kg intramuscularly as asingle dose;PLUS Give nebulized adrenaline, 0.5 ml per kg of 1: 1,000solution in 3 ml of normal saline (maximum dose of 2.5 mlfor ≤ 4 years old and 5 ml for > 4 years).NOTE: Patients who fail to respond to nebulized adrenalinemay require endotracheal intubation. Nebulized adrenalineprovides only temporary relief of airway obstruction lasting 1to 2 hours. Patients should be closely observed after this periodfor recurrence of obstruction.67

3.4 EpiglottitisEpiglottitis is a medical emergency and failure to provideprompt treatment may be fatal. It is due to infection of theepiglottis with Haemophilus influenzae bacteria. Epiglottitismainly affects children between the ages of 3 and 8 years but isoccasionally seen in adults as well. It is characterized by fever,inspiratory and expiratory upper airway noises, a severe sorethroat, dysphagia, and drooling. The patient usually looks veryunwell.There is a very high risk of acute airway obstruction. Allpatients should be referred immediately to an anaesthetist andadmitted to an intensive care unit. Attempting to view thethroat or otherwise upsetting the child may cause airwayobstruction and should be avoided. Keep the patient sitting up. Give ceftriaxone 100 mg per kg stat then 50 mg per kgintravenously daily,OR Give chloramphenicol 40 mg per kg stat then 25 mg per kgintravenously daily.3.5 Oxygen TherapyOxygen is essential for human metabolism and lack of oxygenis generally fatal within 5 to 6 minutes. Oxygen has almost no68

adverse effects in the acute situation and should not bewithheld if there is any suggestion of it being needed.Indications for oxygen therapy include:• cardiac or respiratory arrest• hypoxia of any cause• cardiac failure• myocardial infarction• shock of any cause• carbon monoxide poisoning.Oxygen therapy should be monitored with pulse oximetry andABGs estimation, if available. In general, aim to achieve anoxygen saturation of at least 92% (except in patients who arecarbon dioxide retainers). Humidification of oxygen is notnecessary.3.5.1 Methods of oxygen deliverya. Intranasal cathetersThese provide a low concentration of oxygen of between 25%and 40%. They should be used with an oxygen flow rate ofbetween 1 and 4 liters per minute (1 to 2 liters per minute inchildren). Higher flow rates cause drying of the nasal mucosaand are uncomfortable. They should only be used in patientswith mild hypoxia or cardiac failure or myocardial ischaemia.They do not provide a high enough oxygen concentration forpatients with significant hypoxia, carbon monoxide poisoning,shock, or cardiac arrest.69

. Plastic face masksThese provide oxygen concentrations of between 35% and70%. The oxygen flow rate should be set between 4 and 15liters per minute. Do not use face masks with an oxygen flowrate less than 4 liters per minute. This method of oxygendelivery is suitable for patients with moderate hypoxia orshock.c. Tight fitting face masks (e.g. Laerdal, CPAPmasks)These devices can provide oxygen concentrations close to100%, if available. They should be used in patients with severehypoxia or with cardiac arrest.3.5.2 Adverse effects of oxygenPatients with COPD and elevated carbon dioxide levels mayoccasionally have a hypoxia-dependent respiratory drive. Inthese patients, the administration of oxygen causeshypoventilation and an increase in the carbon dioxide level.Although this may cause problems it is usually far lessdangerous than hypoxia itself. In the emergency situation, it isimportant that hypoxia is corrected – problems with carbondioxide retention can be handled later. Do not hesitate to giveoxygen to hypoxic patients with COPD, but they should beobserved for possible deterioration caused by worseninghypercapnea.70

Administration of 100% oxygen sometimes causes pulmonarytoxicity but this only occurs after 24 hours and therefore is nota problem in the emergency situation.NOTE: If arterial blood gases or pulse oximetry measurementis available, then they should be undertaken before thecommencement of oxygen to establish the baseline insignificantly hypoxic patients or those at risk of carbon dioxideretention.71

4 NeurologicEmergencies4.1 SeizuresThere are numerous causes of epileptic seizures. In adults, themajority occur in known epileptics with idiopathic epilepsywhile in children febrile convulsions are a common cause.However, it is important to exclude less common, reversible,and serious causes of seizures such as hypoglycaemia,hyponatraemia, hypocalcaemia, eclampsia, drug overdose,meningitis, or intracranial lesions.Most seizures are self-limiting and brief. Emergency drugtreatment is only necessary if the seizures are prolonged (>5minutes) or recurrent. Initial treatment is gentle restraint of thepatient in the left lateral position and administration of highflow oxygen via face mask.4.1.1 Treatment in adults Give diazepam 5 mg intravenous bolus and repeat every 2minutes as required to a maximum dose of 20 mg. Thisdose may be repeated 30 minutes later if necessary,OR, if there is no intravenous access,72

Give diazepam 0.5 mg per kg per rectum (use intravenoussolution);PLUS, if seizures persist or are recurrent, Give phenytoin 15 mg per kg via intravenous infusion over20 minutes.NOTE: If seizures persist despite diazepam and phenytoin,THEN diazepam or thiopentone infusions should beconsidered.a. Diazepam infusion Diazepam 100 mg in normal saline to make a total of 100ml solution (strength: 1 mg per ml) and infuse at a rate of2 mg per hour.Patient must be carefully monitored for respiratory depression.b. Thiopentone infusionThe patient should be intubated before the thiopentone infusionis begun. For induction, give thiopentone 5 mg per kg intravenousbolus,THEN73

For induction, give thiopentone 5 mg per kg intravenousbolus,THEN Commence thiopentone infusion at a rate of 1 mg per kgper hour.4.2 MigraineMigraines are recurrent, often unilateral, throbbing headachesassociated with nausea, photophobia, and sometimes visualdisturbance. The diagnosis is usually fairly obvious but it isimportant to consider other causes of headache (e.g. meningitis,subarachnoid haemorrhage) if there are atypical features.4.2.1 Treatment in adultsPatients should rest in a quiet dark room after treatment. Give metoclopramide 10 mg orally or intramuscularly,OR Give prochlorperazine 5 mg orally or 12.5 mgintramuscularly;THEN 15 minutes later,75

Give aspirin 900 mg orally, repeat in 4 hours, if required;PLUS Give paracetamol 1.5 gram orally, repeat in 4 hours, ifrequired.NOTE: Other drugs that can be used in the treatment of acutemigraine include ergotamine preparations and sumatriptan butthey are not available in the Fiji EDL.4.2.2 Treatment in childrenParacetamol alone is usually sufficient along with rest in aquiet dark room. Give paracetamol 20 mg per kg orally or rectally.4.3 Oculogyric CrisisOculogyric crisis is an acute focal dystonic reaction toneuroleptic agents and anti-emetic drugs such asmetoclopramide. It most commonly affects young women. Itis characterised by involuntary deviation of the eyes upwardoften with torticollis (spasm of the neck muscles). Give benztropine 2 mg orally or intramuscularly.NOTE: A further dose of benztropine should be given 4 hours76

later to prevent recurrence.4.4 TetanusTetanus is a severe life-threatening disease caused by the toxinproducing bacterium Clostridium tetani. It usually followslocal wound contamination in an improperly immunizedindividual. Clinical features include muscle rigidity (esp.trismus), painful muscle spasms, fever, labile hypertension, andabnormalities of cardiac rhythm. Patients should be managedin an intensive care unit if possible.4.4.1 Airway and breathingGive high flow oxygen via face mask. Cardiorespiratory statusshould be closely monitored. Patients with respiratory muscleinvolvement will need early intubation, muscle paralysis andventilation.4.4.2 Tetanus immune globulin and immunizationTetanus immunoglobulin neutralizes circulating toxin. Largedoses are required. Give tetanus immune globulin 4,000 units intravenouslyover 30 minutes.Commence active immunization with tetanus toxoid. Give tetanus toxoid 0.5 ml intramuscularly.77

4.4.3 Wound debridementAggressive wound debridement is essential.4.4.4 AntibioticsPenicillin or metronidazole is effective against C. tetani: Give benzylpenicillin 100,000 units per kg (maximum doseof 4 megaunits) intravenously 4-hourly,OR, if penicillin sensitive, Give metronidazole 7.5 mg per kg (maximum dose 500mg) intravenously 8-hourly.4.4.5 Muscle spasmsMorphine and diazepam are used to control muscle spasms.Very large doses may be required. A quiet environment shouldbe maintained.4.5 Acute Bacterial Meningitis in AdultsIn adults, Streptococcus pneumoniae is the most likelyorganism. Haemophilus influenzae and Neisseria meningitidisare less common. Cerebrospinal fluid (CSF) microscopy andculture are vital in directing antibiotic therapy. Therefore, alumbar puncture and blood culture should be performed as78

soon as possible. Caution is required with lumbar puncture ifthe patient is in coma, has signs of increased intracranialpressure, or has focal neurological signs. A computedtomography (CT) scan of the head is preferred before lumbarpuncture if available.Bacterial meningitis is a medical emergency and antibiotictherapy should not be delayed if there is difficulty in obtaininga CSF sample. In such cases, empirical therapy should bestarted immediately.In rural areas or where there is a delay in transferring patient toa major hospital, if meningitis is suspected, antibiotics shouldbe started immediately, either with: Penicillin G 4 megaunits intravenously or intramuscularly6-hourly,OR Ceftriaxone 2 grams intravenously as a single dose (ifavailable).Penicillin, chloramphenicol, and ceftriaxone have proven to beeffective in the treatment of meningitis. Chloramphenicol inoral doses achieves good CSF penetration.Dexamethasone has been found to be useful in children.Recent literature suggests that it has a role in the managementof bacterial meningitis in adults and is to be given just before79

the first antibiotic dose. Dexamethasone 10 mg intravenously just before the firstdose of antibiotic followed by 10 mg intravenously 6-hourly for 4 days.4.5.1 Empirical therapy Penicillin G 1.8 gram (3 megaunits) intravenously 4-hourly for 10 days,PLUS Chloramphenicol 750 mg to 1 gram intravenously 6-hourlyfor 10 days.In patients hypersensitive to penicillin: Chloramphenicol alone,OR Ceftriaxone 4 grams intravenously daily in one or twodivided doses.Change to appropriate regimen once the organism andsusceptibility result are available. If no organism is identified,continue empirical therapy for a total of 10 days.80

4.5.2 Specific therapya. Streptococcus pneumoniae and Neisseriameningitidis meningitis Penicillin G 1.8 gram (3 megaunits) intravenously 4-hourly.In penicillin hypersensitive patients: Ceftriaxone 4 grams intravenously daily in two divideddoses.Pneumococcal meningitis is to be treated for 10 to 14 days.Some very ill patients may require treatment for 21 days.Meningitis due to Neisseria meningitidis usually requirestreatment for 7 days only.NOTE: At the end of penicillin therapy, rifampicin 10 mg perkg per dose (up to 600 mg) orally 12-hourly for 4 doses shouldbe given to eradicate nasopharyngeal carriage in cases ofmeningococcal meningitis. This treatment should also be givento all close contacts.b. Gram negative bacterial meningitisConsultation is advisable. Generally, for gram-negativemeningitis not due to H. influenzae, a combination ofceftriaxone and gentamicin is useful and the treatment is for 21days.81

5 Poisoning andOverdosesPoisoning may occur with both chemicals (e.g. insecticides) orwith therapeutic drugs, many of which can be toxic inoverdose. Poisoning and overdose may or may not be lifethreatening,depending on the type and amount of substanceingested. Treatment is most often supportive only and careshould be taken that any intervention does not worsen thesituation. Below are the steps to be taken in most cases ofpoisoning.5.1 General Principles5.1.1 Resuscitation (see Section 2.1)• Rapidly assess the airway, breathing, and circulation.• Maintain the airway, if necessary.• Administer oxygen.• Obtain intravenous access.• Give intravenous fluids if the patient is hypotensive.NOTE: Oxygen should be avoided unless absolutelynecessary in patients with paraquat poisoning as it mayincrease toxicity.82

5.1.2 Gastric decontaminationThe best method of preventing absorption of ingested poisonsis with the use of activated charcoal. Give activated charcoal 1 gram per kg (to a maximum of50 grams) orally or via nasogastric tube.Patients who are unable to protect their airway (i.e. excessivedrowsiness) should be intubated BEFORE insertion of anasogastric tube and administration of activated charcoal.In CHILDREN: Give activated charcoal 15 to 30 grams if under 12 yearsold and 50 to 60 grams if over 12 years of age.NOTE: Ipecac syrup has no role in the treatment of poisoning.Gastric lavage should be performed only in exceptionalcircumstances such as recent ingestion of large doses ofparacetamol. Gastric lavage is contraindicated in ingestion ofhydrocarbons, caustics, and corrosives.Administration of activated charcoal is the easiest, safest, andmost effective method of decontamination of the gut in almostall situations. In paraquat poisoning, Fuller’s earth (ifavailable) should be substituted for activated charcoal.Activated charcoal does not effectively absorb hydrocarbons,anticholinesterase insecticides, heavy metals, or acids andalkalis, but it is unlikely to cause harm in these situations and83

may still be given, especially if there is doubt about exactlywhat the patient has ingested.5.1.3 Supportive careContinued observation and the provision of oxygen,intravenous fluids and airway support as required. Knowledgeof the pharmacologic effects of the substance ingested allowsanticipation of possible problems.5.1.4 Specific antidotesAntidotes to a number of drugs exist and their use is describedin the sections below.5.1.5 Psychiatric evaluationSelf-administered overdoses are more often expressions ofdistress due to emotional crises than true suicide attempts. Allpatients should be assessed for suicidal intent and treatedappropriately. Appropriate counseling should be given prior todischarge.5.2 Treatment of Specific Poisons5.2.1 Opiates (e.g. codeine, heroin, pethidine,morphine, methadone)These drugs cause depression of conscious state and84

hypoventilation. Particular attention should be paid to themaintenance of the airway and adequate ventilation. Thespecific antidote naloxone is highly effective. Give naloxone 0.4 mg intravenously or intramuscularlyand repeat in 5 minutes if necessary to a maximum of 2mg.NOTE:• Failure to respond to a dose of 2 mg of naloxone is anindication that the depression of conscious state is not dueto opiate ingestion alone – other possible causes should beconsidered.• Naloxone has a short half-life and further intramusculardoses may be required after 1 to 2 hours.• Naloxone may induce pulmonary oedema.5.2.2 ParacetamolOverdose of this drug is common and can be fatal. Initialsymptoms are mild with nausea, vomiting, and sometimesabdominal pain. Hepatic failure and death may follow in daysto weeks. The minimum toxic dose is 150 mg per kg andalmost all patients who ingest more than 350 mg per kg willdevelop hepatic failure. Acetylcysteine is the specific antidoteand if given within 8 hours may largely prevent hepaticdamage. It may still be useful when given from 8 to 24 hoursafter the ingestion.85

If urgent serum paracetamol levels are available, then anassessment of the risk of hepatic damage is done using theRumack-Matthew nomogram which relates serum paracetamollevels to time since ingestion. If a paracetamol level isavailable within 8 hours of ingestion then withholdacetylcysteine until a toxic level is confirmed. If a paracetamollevel will not be available within 8 hours of ingestion, thenacetylcysteine should be commenced immediately. If there isany doubt about the time of ingestion or if paracetamollevels are not available, then acetylcysteine should be givento all patients in whom it is reasonably certain that theyhave ingested an overdose of paracetamol. Give acetylcysteine 150 mg per kg intravenously over 15minutes,THEN Give acetylcysteine 50 mg per kg intravenously over 4hours.THEN Give acetylcysteine 100 mg per intravenously over 16hours.NOTE: Acetylcysteine may cause severe bronchospasm insome individuals. If this occurs the infusion should be ceasedand salbutamol administered. Hydroxycobalmin has beenused as an alternative antidote.86

5.2.3 Anticholinesterases (e.g. insecticides)These substances cause severe cholinergic effects includingvomiting, diarrhoea, bradycardia, hypotension, hypersalivation,bronchospasm, urinary incontinence, muscle weakness,constricted pupils, and pulmonary oedema. Poisoning mayoccur with skin exposure or inhalation, as well as with oralingestion. The specific antidote is atropine and very largedoses may be required. Atropine will not reverse muscleweakness so intubation and mechanical support of ventilationmay be required. Pralidoxime, which is anacetylcholinesterase reactivator, may also be useful,particularly if administered in conjunction with atropine.a. Treatment in adults Give atropine 3 mg intravenously every 5 to 15 minutesuntil atropinization is achieved (dry mouth, tachycardia,pupillary dilatation). There is no maximum dose;however, 20 or 30 mg may be required;PLUS Pralidoxime 1gram intravenously over 30 minutes andrepeat every 12 hours if symptoms persist.b. Treatment in children Give atropine 1.2 mg intravenously every 5 minutes untilthe patient develops sinus tachycardia (heart rate of up to87

120 beats per minute). There is no maximum dose.PLUS Pralidoxime 20 mg per kg intravenously over 30 minutesand repeat every 12 hours if symptoms persist.NOTE: Further doses of atropine may be needed for 24 to 48hours after exposure.5.2.4 Aliphatic hydrocarbons (e.g. kerosene,petroleum)Hydrocarbons cause irritation of the gastrointestinal tract, withcommon symptoms being abdominal pain, vomiting, anddiarrhoea. Their most dangerous toxic effects occur when theyare aspirated into the lungs causing a chemical pneumonitis.This may occur either during the primary ingestion or when thepatient subsequently vomits. Hydrocarbons are not absorbedby activated charcoal so this should not be given. Patientswho have any signs or symptoms of aspiration pneumonitis(e.g. fever, cough, dyspnea, wheeze) should be given oxygen,admitted for observation, and administration of intravenousantibiotics should be considered. Patients with severe vomitingand diarrhoea may need intravenous hydration. There is nospecific antidote for these chemicals.5.2.5 Alkali ingestion (e.g. bleach, drain cleaner)Gastric decontamination is not indicated in alkali ingestion and88

vomiting should be avoided. There is no specific antidote; thetreatment is supportive only.Ingestion of an alkaline substance causes damage to theoropharynx and oesophagus. Household bleach (5% sodiumhypochlorite) is not a very strongly alkaline substance and isunlikely to cause serious injury. These patients need onlysymptomatic treatment with intravenous fluids and admissionfor observation. Stronger alkalis such as drain cleaner maycause severe chemical burns the complications of whichinclude airway obstruction and oesophageal or gastricperforation. These patients should be admitted for rehydrationand consideration of upper gastrointestinal endoscopy todetermine the extent of the damage.5.2.6 Oral anticoagulants (e.g. warfarin, rat poison)Overdose of these substances causes prolongation of theprothrombin time and increased risk of bleeding. Patients whohave active bleeding or who are at high risk of developingbleeding (e.g. post-operative) should be actively treated.Vitamin K reverses the effect of oral anticoagulants over 12 to24 hours whereas fresh frozen plasma provides immediatereplacement of coagulation factors. In patients not at immediaterisk, ceasing warfarin temporarily until the prothrombin time isin the therapeutic range is all that is required. The potency ofrat poisons vary – some may require large doses of vitamin Kover several weeks.89

a. Treatment in adults Give vitamin K 5 to10 mg intravenously slowly stat;PLUS, if necessary, Give fresh frozen plasma 2 units intravenously and repeatas necessary to a maximum of 8 units using repeatedmeasurements of the prothrombin time as a guide totherapy.Refer to consultant physician for subsequent management.b. Treatment in children Give vitamin K, 0.3 mg per kg (maximum 10 mg)intramuscularly daily;PLUS, if necessary, Give fresh frozen plasma 20 ml per kg (maximum 2 units)intravenously and repeat as necessary using repeatedmeasurements of the prothrombin time as a guide totherapy5.2.7 Beta-adrenergic antagonists (e.g. propranolol,atenolol)Beta-blocker overdose causes bradycardia, AV node block andhypotension, sometimes complicated by bronchospasm,90

congestive cardiac failure, and confusion. Hypoglycaemia mayalso occur in children. These overdoses may be fatal andpatients with significant toxic effects may need a centralvenous line, ECG monitoring, and monitoring in an intensivecare unit (if available).a. Treatment in adults Give adrenaline infusion 10 micrograms per minute andincrease by 5 micrograms per minute every 2 minutes untilthe systolic blood pressure is >90 mmHg, to a maximum of100 micrograms per minute.b. Treatment in children Give adrenaline infusion 0.5 micrograms per kg perminute and increase by 5 micrograms per minute every 2minutes until the systolic blood pressure is >90 mmHg, toa maximum of 100 micrograms per minute;OR Give isoprenaline infusion 0.5 to 10 micrograms per kgper minute.5.2.8 IronOverdose of iron initially causes vomiting, diarrhoea,abdominal pain, and sometimes haematemesis. After a variable91

quiescent period during which these gastrointestinal symptomsresolve, the patient may develop shock and hypoglycaemia pluscardiac, hepatic, and renal failure. The specific antidote isdesferrioxamine but supportive care including intravenous fluidand glucose (if necessary) is important as well. Iron is not wellabsorbed by activated charcoal.The following patients should receive desferrioxamine:• all symptomatic patients• all patients who have iron tablets visible on a plainabdominal X-ray• all patients in whom the serum iron level (if available) isgreater than 350 micrograms per dl (90 micromoles perliter). Give desferrioxamine 15 mg per kg per hour byintravenous infusion continued until the patient isasymptomatic (usually 12 to 24 hours).5.2.9 Benzodiazepines (e.g. diazepam)These substances are very safe in overdose generally causingonly drowsiness. Supportive care and observation is usually allthat is necessary.5.2.10 Nonsteroidal anti-inflammatory dugs (e.g.indomethacin, ibuprofen, aspirin)Overdose of these drugs causes nausea, vomiting, abdominal92

pain, and drowsiness. Treatment is supportive only.5.2.11 PhenytoinIn overdose, phenytoin causes cerebellar dysfunction(nystagmus, ataxia, dysarthria, nausea, and vomiting) plusconfusion, coma and paradoxically, seizures. Treatment isessentially supportive. Diazepam should be used to controlseizures.5.2.12 AspirinThis commonly used drug can be highly toxic in overdose. Theclinical features include gastrointestinal (nausea, vomiting,haematemesis), neurologic (confusion, coma, seizures), andmetabolic (fever, tachypnea, and hypokalaemia)manifestations. Metabolic acidosis and hypoglycaemia mayoccur in children. Cardiac failure and acute respiratorydistress syndrome are uncommon complications. Thepotentially toxic dose is greater than 150 mg per kg. Patientswith manifestations of aspirin overdose should be admitted andtreated as follows: Give 0.9% saline (or 0.3% saline with 3% dextrose inchildren) intravenously at a rate necessary to maintain aurine output greater than 2 ml per kg per hour;PLUS Give sodium bicarbonate 1 mmol per kg intravenously93

every 4 hours to maintain a urine pH greater than 7.5 iffacilities are available;PLUS Give potassium chloride 0.25 mmol per kg intravenouslyover at least one hour, every 4 hours to maintain serumpotassium levels > 4 mmol per liter.NOTE: Frequent measurement of urine output, urine pH, andserum potassium should be performed (e.g. every 2 to 4 hours).Larger or smaller doses of sodium bicarbonate and potassiumchloride than those listed above may be required.5.2.13 Carbon monoxide (e.g. car exhaust)This odourless and colourless gas competes with oxygen forthe binding sites on the haemoglobin molecule. Toxic effectsinclude headache, nausea, confusion, coma, seizures, andcardiac arrhythmias. Treatment for symptomatic patients iswith 100% oxygen for at least 12 hours.5.2.14 DigoxinPoisoning with this drug may be acute (usually intentional selfpoisoning)or chronic (gradual accumulation in a patient takingdigoxin for therapeutic reasons). Patients with significanttoxicity always complain of nausea and vomiting. Otherclinical features include headache, diarrhoea, visual disorders,confusion, and coma. Acute poisoning causes marked94

hyperkalaemia whereas chronic toxicity cases are oftenhypokalaemic. Digoxin toxicity has been known to cause justabout every type of cardiac arrhythmia from complete heartblock to ventricular tachycardia. In addition to the usualsupportive care, complications should be treated as follows:a. Ventricular tachycardia Give phenytoin 15 mg per kg intravenously, infused nofaster than 50 mg per minute;PLUS Give magnesium sulphate 50 mg per kg intravenously(maximum dose 5 grams) over 5 minutes.THEN, if arrhythmia persists, Give lignocaine 1 mg per kg intravenous bolus.NOTE: Use cardioversion only as a last resort as it may induceintractable ventricular fibrillation. If it is absolutely necessarythen use low energies (e.g. 25 joules in an adult).b. Bradyarrhythmias Give atropine 10 micrograms per kg intravenous bolusand repeat in 5 minutes, if necessary.95

c. Hyperkalaemia (serum potassium >6 mmolper liter)i. Treatment in adults Give short-acting insulin 10 units intravenousbolus,PLUS, at the same time, Give 50 ml of 50% glucose intravenously over 5minutes.ii.Treatment in children Give short-acting insulin 0.1 unit per kgintravenous bolus,PLUS, at the same time, Give 50% glucose 2 ml per kg intravenously over5 minutes.NOTE: Serum glucose should be monitored hourlyover the next 4 hours. Calcium should not be given topatients with digoxin toxicity. The above treatment forhyperkalaemia may be repeated in 2 hours ifnecessary. Refer to Section 7.1 for subsequentmanagement.96

5.2.15 Barbiturates (e.g. phenobarbitone)In overdose, barbiturates can cause severe central nervoussystem depression with coma, hypoventilation, andhypotension. Patients with significant ingestions will needintensive supportive care. There is no specific antidote.5.2.16 TheophyllineTheophylline poisoning may occur because of deliberateingestion of an overdose or due to gradual accumulation of thedrug in those taking it for therapeutic reasons. Toxicity affectsseveral organ systems:• cardiovascular – supraventricular and ventriculartachycardia, atrial fibrillation• gastrointestinal – nausea, vomiting, and diarrhoea• neurologic – agitation, confusion, seizures• metabolic – hypokalaemia, hyperglycaemia.Seizures may be resistant to treatment with benzodiazepines;intubation and sedation with barbiturates may be required.Hypokalaemia should be treated with intravenous potassiumreplacement (see Section 7.2), while tachyarrhythmias mayrespond to beta-adrenergic antagonists.For supraventricular or ventricular tachycardia: Give propranolol 0.5 mg intravenous bolus and repeatevery 2 minutes up to a maximum of 10 mg.97

Note: Propranolol is contraindicated in patients withasthma.5.2.17 ChloroquineThis drug is highly toxic in overdose causing hypotension andcardiac arrhythmias. Treatment involves adrenaline and verylarge doses of diazepam. Most patients will require intubationand management in an intensive care unit (if available). Give adrenaline 0.25 microgram per kg per minute viaintravenous infusion and increase rate by 5 microgramsper minute until systolic blood pressure is greater than 90mmHg;PLUS Give diazepam 2 mg per kg intravenously over 30 minutes.5.2.18 VerapamilThe minimum toxic dose of verapamil in an adult is about onegram. Its main effects are upon the heart where it causeshypotension, bradycardia, and heart block. The specificantidote is calcium. In addition, bradycardia may requiretreatment with atropine (see Section 1.3) and hypotension mayrequire inotropes (see Section 1.10). Give 5 ml of 10% calcium chloride (equals about 1 gramof elemental calcium) intravenously over 5 minutes.98

Further doses may be required according to response.5.2.19 Tricyclic antidepressants (e.g. amitriptyline,doxepin, imipramine)These agents are very dangerous in overdose. The mostimportant toxic effects are on the cardiovascular system(hypotension and ventricular tachycardia) and the centralnervous system (coma and seizures). Toxicity is greatlyenhanced in the presence of acidosis. Respiratory acidosis dueto depressed conscious state may occur and should be promptlytreated with intubation and ventilation. Seizures andhypotension may cause metabolic acidosis and also should bepromptly treated. All patients should be observed, preferablywith cardiac monitoring for at least 24 hours. Patients whoexhibit no signs of toxicity at that time (including sinustachycardia or QRS widening > 0.12 seconds) can bedischarged safely.a. Seizures Give diazepam 0.1 mg per kg intravenous bolus and repeatin 5 minutes, if necessary.NOTE: Phenytoin is not effective in this situation. If seizurespersist despite 2 doses of diazepam then the patient requiresintubation and sedation with barbiturates.99

. Hypotension If venous venous pressure is not increased, give 0.9%saline boluses of 100 ml intravenously until a systolicblood pressure is ≥ 90 mm Hg.NOTE: If hypotension persists despite the above measuresthen inotropes may be necessary (see Section 1.10).c. Ventricular tachycardia Give lignocaine 1 mg per kg intravenous bolus.NOTE: If ventricular arrhythmias persist or the patientbecomes unstable then treat with synchronized cardioversion(see Section 2.5.1).5.2.20 Phenothiazines (e.g. chlorpromazine,haloperidol, promethazine, fluphenazine,thioridazine, trifluoperazine)Drugs in this class cause sedation, hypotension andoccasionally torsade de pointes (see Section 2.5.1) in overdose.Anticholinergic symptoms such as dry mouth, sinustachycardia, and urinary retention may occur especially withchlorpromazine and thioridazine. Complications of therapeuticdoses include oculogyric crisis (see Section 4.3). Treatment ismainly supportive.100

5.2.21 LithiumAcute lithium overdose mainly affects the gastrointestinalsystem (nausea, vomiting, and diarrhoea) and the centralnervous system (tremor, hyperreflexia, ataxia, confusion,seizures, and coma). Treatment is supportive and includeshydration with adequate amounts of 0.9% saline intravenouslyto maintain a good diuresis and enhance lithium excretion.5.2.22 Ciguatera poisoningThis syndrome is caused by ingestion of certain reef fish(especially red bass or damu). It is characterised by nausea,vomiting, and dysthesias (especially abnormal temperatureperception when placing the hands in water). Other symptomsinclude headache, myalgia, diarrhoea, tremor, itching, andsweating. On examination, patients often have a mild sinusbradycardia. Severity varies greatly. Treat dehydration asdescribed in Section 7.5.NOTE: Patients may present with ECG changes that maymimic ischaemic heart disease. For bradycardia and vomiting: Give atropine 10 micrograms per kg intravenously orintramuscularly to a maximum of 1.2 mg.If symptoms have been present for less than 24 hours thenmannitol is often useful. Patients must be adequatelyrehydrated with 0.9% saline prior to administration ofmannitol.101

Give 20% mannitol 1gram per kg (200 ml) intravenouslyover 30 minutes. Consider promethazine 25mg intramuscularly or 20 mgorally for symptomatic treatment.5.2.23 Paraquat poisoning (e.g. Gramaxone)Paraquat poisoning is extremely serious and even a fewmilliliters of concentrated paraquat can be fatal. Rapidtreatment is essential within 4 hours and certainly no longerthan 12 hours. However, treatment must not be withheldbecause a longer period has elapsed. All cases should beadmitted for close clinical and biochemical monitoring.Steps:• Give stomach washout.• Give 120 grams Fuller’s earth (2 × 60 gram containers)mixed with 800 ml of water orally or by gastric tube(within 4 hours of ingestion, if possible). If Fuller’s earthis not available, activated charcoal may be used.• Following this, give as a purgative 200 ml (for an adult) of20% mannitol orally or via a nasogastric tube.• Repeat administration of Fuller’s earth and mannitol untilthe stools are seen to contain Fuller’s earth. This may takebetween 4 to 6 hours after the administration of thepurgative.• Close clinical and biochemical monitoring is necessary.• Delay the use of oxygen (at least 48 hours) as it enhancesthe toxicity of paraquat.102

• General supportive measures may include:• Use of antibiotics for aspiration pneumonia• Care of mouth and throat ulcers.5.3 Poisons InformationYou may contact:New Zealand National Poisons CentreOffice 9am-5pm weekdays: Tel 643 479 724824 hour emergency: Tel 643 474 7000Fax: 643 477 0509E-mail: poisons@otago.ac.nzAddress: National Poisons CentreDepartment of Preventive and Social MedicineUniversity of OtagoPO Box 913DunedinNEW ZEALAND103

6 EndocrineEmergencies6.1 Diabetic KetoacidosisDiabetic ketoacidosis (DKA) is a life-threatening complicationoccurring mostly in patients suffering from type 1 diabetesmellitus. DKA usually occurs in the setting of an intercurrentinfective illness, or of missed insulin doses, and ischaracterised by hyperglycaemia, ketosis, and acidosis. DKAcan be the first presentation of an undiagnosed type 1 diabetesmellitus.6.2.1 ManagementManagement should be undertaken urgently in the nearesthealth care facility.a. Airway and breathingAll patients should be given oxygen via a face mask. Inpatients who are drowsy and are vomiting, insertion of anasogastric tube is recommended to limit regurgitation andaspiration.104

. Intravenous fluidsModerate to severe dehydration is always present in DKA.Initially fluid resuscitation should be with large volumes ofnormal saline. When the blood glucose falls to

If infusion pumps are not available, use the microsetintravenous giving set used in paediatrics to achieve therequired infusion rate.If venous access cannot be established, give: Short-acting insulin intramuscularly 8 units per hour.Blood sugar should be measured every hour andinsulin doses adjusted 1 . Insulin doses can be halvedwhen the blood glucose reaches ≤12 mmol per liter.Thereafter, insulin can be changed to multiple-dose(“QID”) insulin regimen subcutaneously followed bytwice-daily dosing.d. Electrolytesi. PotassiumInsulin drives glucose and potassium into the cells andtheir respective serum concentrations fall. If serumpotassium is not elevated, a safe and cautiousapproach is to initiate supplementary intravenouspotassium at a rate of no more than 10 to 20 mmol perhour once insulin and fluids have been started, andwhen renal function and urinary output have beenassessed as satisfactory.1 For adjustment of doses of insulin infusion, refer to theAppendix.106

Measure serum potassium along with serum sodiumevery 4 to 6 hours.ii.BicarbonateSodium bicarbonate should not be given routinely. Itis only considered when the blood pH is less than 7.0.In such cases, infuse 50 mmol of sodium bicarbonateover one hour.e. Treatment of underlying causeTreat the underlying cause especially infection.f. Other measuresAn indwelling catheter should be inserted to monitor urineoutput. Other measures that may be required are: oxygentherapy and insertion of nasogastric tube if paralytic ileusdevelops.On recovery, every patient with DKA should be re-educatedabout avoidance of the complication and the recognition ofearly warning signs and symptoms.107

6.2.2 Special considerations in children (but alwayscontact a paediatrician)Rehydration is critical. The degree of dehydration should beassessed as follows:Mild (3% or less) – just clinically detectable.Moderate (around 6%) – easily, reduced skin turgor, poorcapillary return.Severe (10%) – poor perfusion, rapid pulse, reduced bloodpressure.Normal saline is the recommended intravenous fluid forrehydration.Deficits should be replaced gradually (over 24 to 48 hours) andnot with rapid infusion as is appropriate for adults. Tables toguide the rate of fluid replacement according to body weightand degree of dehydration are available at pediatric units ofrespective divisional hospitals.6.2 Hyperosmolar, Hyperglycaemic StateThis is a relatively uncommon event usually occurring as adramatic presenting feature or as a complication of type 2diabetes mellitus.It presents with a history of thirst, polyuria, and progressiveimpairment of consciousness commonly in a patient who is 60years or older. It differs from DKA in that patients in108

hyperosmolar, hyperglycaemic state do not developketoacidosis.Investigations reveal very high blood glucose (usually higherthan 30 mmol per liter) the serum sodium is often elevated, andthe calculated serum osmolality >320 mOsm per liter 2 .The treatment is similar to that in DKA (see Section 6.1 above).Intravenous isotonic saline, low dose intravenous insulin (4 to 6units per hour by infusion), and careful attention to serumpotassium concentrations are the central strategies. Carefulmonitoring is required as in DKA.On recovery, the patient may not need long-term insulintherapy. After an initial period of stabilisation with insulin,most patients with type 2 diabetes mellitus who present in ahyperosmolor, hyperglycaemic state can be controlled with oralhypoglycaemic drugs combined with diet.6.3 Adrenal InsufficiencyAdrenal insufficiency is most often due to sudden cessation oflong-term corticosteroid treatment (≥10 mg prednisolone orprednisone daily generally for more than 2 weeks). Other2 Serum osmolality = 2 (Na + K) + urea (mmol per liter) +blood sugar (mmol per liter).109

causes include Addison’s disease, adrenal tumours, andmeningococcal septicaemia. Clinical features are non-specificand include anorexia, nausea, vomiting, lethargy, and posturalhypotension. Blood chemistry usually reveals hyperkalaemia,hyponatraemia, and an elevated urea level. Hypoglycaemiacommonly occurs.6.3.1 Treatment in adultsa. Intravenous fluidsUse normal saline to correct hyponatraemia and dehydration. Give 0.9% saline 1,000 ml intravenously over 1 hour,THEN Give 0.9% saline 1,000 ml intravenously over 2 hours,THEN Give 0.9% saline 1,000 ml intravenously over 4 hours andrepeat as necessary.b. Corticosteroids Give hydrocortisone 200 mg intravenous bolus then give100 mg intravenously 6- hourly.110

6.3.2 Treatment in childrena. Intravenous fluidsUse normal saline to correct hyponatraemia and dehydration. Give 0.9% saline 20 ml per kg intravenously over 1 hour,THEN Give 0.9% saline intravenously at the rate necessary tocorrect the estimated fluid deficit plus maintenancerequirements over the next 24 hours.b. Corticosteroids Give hydrocortisone 3 mg per kg intravenous bolus then 1mg per kg 6- hourly.If the patient is usually taking steroids, and the usual dose isknown, give 4 times the dose the patient is usually taking.NOTE: See Section 7.5 for calculation of paediatric fluiddeficits. Treat hypoglycaemia as described in Section 6.4below.6.4 HypoglycaemiaPatients should be treated urgently.111

If the patient is conscious and able to swallow, give a sugaryfood or drink, followed by foods that are absorbed longer, e.g.crackers.If the patient is unable to swallow or unconscious at home, givesugar paste or honey into the mouth, and transfer immediatelyto the nearest health care facility for intravenous glucosetherapy. At the health care facility, if the patient isunconscious or unable to swallow: Give 30 to 50 ml dextrose 50% intravenously followed bycontinuous intravenous infusion of 5% dextrose for up to24 hours.Hypoglycaemia in the elderly, particularly as a consequence ofaccumulation of sulphonylurea in the plasma, may be difficultto reverse and may re-occur for several days after stopping thedrug.NOTE: Oral hypoglycaemics have long half-lives particularlyin renal failure (e.g. 12 hours for glibenclamide), so relapse ofhypoglycaemia may occur if these drugs have been taken inoverdose. Admission for observation may be needed. Althoughthe sympathetic signs of hypoglycaemia resolve within minutesof the administration of glucose, the neuroglycopenic featuresmay take up to 30 minutes to resolve completely. Glucagonwill not reverse hypoglycaemia if the hepatic glycogen storesare exhausted (e.g. starvation, alcoholism).112

6.5 Thyroid StormThyroid storm is diagnosed by the presence of prominent signsof hyperthyroidism plus fever and central nervous systemdysfunction (confusion, coma, seizures). It is a rare medicalemergency requiring prompt intensive treatment.6.5.1 Airway and breathingGive high flow oxygen via a face mask. Unconscious patientsmay need intubation.6.5.2 Intravenous fluidsObtain intravenous access. Dehydrated or shocked patientsshould be resuscitated with 0.9% saline.6.5.3 Beta-adrenergic antagonistsThese drugs antagonise the peripheral effects of thyroidhormone. Cardiac monitoring is desirable. Give propranolol 0.5 mg intravenous bolus every 2minutes to a maximum of 10 mg using control oftachycardia (pulse

8- hourly thereafter.6.6 Myxedema Coma (Hypothyroid Crisis)Hypothyroid crisis occurs in patients with long standinghypothyroidism who are exposed to an extra physiologicalstress that causes decompensation. The stress is usually anintercurrent illness such as pneumonia or stroke. Treatmentshould be directed at the underlying cause of thedecompensation as well as by hypothyroidism itself. Thiscondition has a very high mortality. Clinically these patientshave signs and symptoms of longstanding hypothyroidism plushypotension, hypothermia, confusion, coma, and seizures.Biochemical abnormalities include hyponatraemia andhypoglycaemia.6.6.1 Airway and breathingOxygen should be supplied via a face mask. Intubation andventilation will be required for comatose patients.6.6.2 Intravenous fluidsDespite their oedematous appearance, most patients haveintravascular fluid depletion. This should be corrected bycareful administration of 0.9% saline intravenously.Monitoring of central venous pressure and urine output isdesirable.114

6.6.3 CorticosteroidsMost patients have a co-existing adrenal insufficiency. Give hydrocortisone 200 mg intravenously stat then 100mg intravenously 6-hourly thereafter.Corticosteroids should be given before the administration ofthyroid hormone.6.6.4 Thyroid hormoneReplacement of thyroid hormone is the definitive treatment forhypothyroidism but it should be done slowly over several days. Give thyroxine 10 micrograms per kg via nasogastric tubeas a single dose then 100 micrograms per day.NOTE: The dose should be reduced in patients suffering fromischemic heart disease.6.7 PhaeochromocytomaPhaeochromocytoma is a catecholamine-producing tumourusually located in the adrenal glands. These tumours causeparoxysmal swings in the blood pressure along with sweating,palpitations, and headache. Definitive treatment is surgicalexcision of the tumour but in the emergency situation control ofthe blood pressure is important.115

Give labetalol 0.2 mg per kg intravenously and repeatevery 10 minutes.116

7 Fluid and ElectrolyteEmergencies7.1 HyperkalaemiaThe organ principally affected by hyperkalaemia is the heartand this can lead to heart block, bradycardia, ventricularfibrillation, and asystole. In all cases the cause of thehyperkalaemia should be established and corrected if possible.The treatments below are mostly temporary measures to lowerthe serum potassium level. A 12-lead ECG and monitoring isdesirable, as ECG changes, if present, indicate that emergencytreatment is needed. In general, the higher the potassium level,the more urgent it should be lowered.7.1.1 Mild hyperkalaemia (serum potassium

7.1.2 Moderate to severe hyperkalaemia (serumpotassium >6.0 mmol per liter)Treat as for mild hyperkalaemia. In addition, consider givinginsulin-dextrose and/or sodium bicarbonate.a. Treatment in adults Give short-acting insulin 10 units intravenous bolus,PLUS Give 50 ml of 50% dextrose or glucose intravenously over5 minutes.For persistent hyperkalemia, consider giving: Sodium bicarbonate 8.4%, 100 mmol, intravenously over 5minutes.For intractable hyperkalaemia attributable to acute renal failure,consider peritoneal dialysis.b. Treatment in children Give neutral or short-acting insulin 0.1 units per kgintravenous bolus;PLUS, at the same time,118

Give 50% dextrose or glucose 2 ml per kg intravenouslyover 5 minutes;PLUS Give sodium bicarbonate 1 mmol per kg intravenouslyover 5 minutes.NOTE: Serum glucose should be monitored hourly over thenext 4 hours. The above treatment for hyperkalaemia may berepeated in 2 hours if necessary.If hyperkalemia is accompanied with cardiac arrhythmias, give: 10% calcium chloride, 0.2 ml per kg (to a maximum of 10ml) intravenously over 5 minutes.Calcium should not be given to patients with digoxin toxicity.7.2 HypokalaemiaHypokalaemia can cause muscle weakness and cardiacarrhythmias. Patients with pre-existing cardiac disease(especially ischaemic heart disease and those on digoxintherapy) may be at increased risk of cardiac arrhythmias causedby hypokalaemia.For mild deficiencies, oral potassium replacement is sufficient.One 600-mg tablet of potassium chloride contains about 8119

mmol of potassium. As a general guide, if the serum potassiumis >3.0 mmol per liter and the patient is asymptomatic, giveoral potassium chloride. If the serum potassium is 2.5 to 3.0mmol per liter, oral potassium chloride may be sufficient. Butif hypokalaemia is acute in onset and/or the patient hassignificant heart disease, intravenous potassium chloride shouldbe considered. If the serum potassium is

Close monitoring of fluid status is important especially inelderly patients to avoid over or underhydration.Treatment of hypercalcaemia should be based on the ionizedcalcium rather than the total calcium level. The normal totalserum calcium level is 2.1 to 2.6 mmol per liter but the ionizedfraction will vary with blood pH and serum albumin levels.Calcium levels should be corrected to account for changes inalbumin level. The corrected calcium = patient’s serum calciumvalue + [(40 – serum albumin) x 0.02]. Give 0.9% saline 15 ml per kg intravenously every 4hours,PLUS Give frusemide 0.5 mg per kg intravenously every 4 hours.NOTE: Adjustment of the frusemide dose may be necessary toavoid dehydration or fluid overload.7.4 HypocalcaemiaHypocalcaemia may cause confusion, seizures, neuromuscularirritability, cardiac failure, heart block, and ventricularfibrillation. Symptoms generally do not appear until the serumcalcium is less than 2.0 mmol per liter. For acute treatment: Give 10% calcium chloride 0.1 ml per kg (to a maximum121

of 5 ml) intravenously over 5 minutes and repeat in 30minutes if necessary;PLUS, if symptoms fail to resolve, Give magnesium sulphate 0.1 mmol per kg intravenouslyover 5 minutes.7.5 Fluid resuscitationThe basic principles of fluid resuscitation are:• Accurate assessment of fluid deficits.• Replacement with a fluid that approximates thecomposition of the fluid that was lost.• Continuous reassessment of hydration status.7.5.1 Assessing fluid deficitsEstimation of a fluid deficit is mainly via clinical assessment.Measurement of the blood urea may also be useful butelevation is usually delayed and only occurs with moderate tosevere dehydration. Signs of dehydration include reducedtissue turgor, dry skin and mucous membranes, tachycardia,postural hypotension, low JVP, mild fever, and reduced urineoutput. Hypotension and acidosis are late signs and signal thedevelopment of hypovolaemic shock.122

7.5.2 Selection of replacement fluidThe basic principle is to replace the deficit with a similar fluid.In most cases, the fluid lost is similar to the extracellular fluid,containing mainly sodium and chloride. Potassium losses vary.Sometimes fluid with a low sodium content is lost causing ahypernatraemic dehydration. On other occasions sodium, richfluids are lost causing a hyponatraemic dehydration.No matter what fluid has been lost, the initial treatment forsevere dehydration is administration of normal saline. Afterinitial resuscitation, subsequent fluid therapy should be basedon measured levels of plasma sodium and potassium.7.5.3 ReassessmentOngoing reassessment is necessary, particularly of urineoutput. The best sign of adequate hydration is a urine outputexceeding 0.5 ml per kg per hour.7.5.4 Hypovolaemic shock Give 0.9% saline 10 ml per kg intravenous bolus andrepeat if necessary.Consider the use of plasma expanding solution such asHaemaccel or Gelofusine.123

7.5.5 Maintenance requirements each 24 hoursThese maintenance requirements are averages only. The actualfluid requirements will vary from patient to patient and withfactors such as the presence or absence of fever, and ongoinglosses.a. AdultsWaterSodiumPotassium- 40 ml per kg- 2 mmol per kg- 2 mmol per kgb. ChildrenWater - 100 ml per kg for the first 10 kg of bodybody weight then, 50 ml per kg for the next10 kg of body weight then, 20 ml per kgthereafterSodium - 2 to 3 mmol per kgPotassium - 2 mmol per kg124

8 MiscellaneousEmergencies8.1 AnaphylaxisAllergic reactions may be triggered by a variety of factorsincluding drugs (e.g. penicillin), foods (e.g. shellfish), insectstings, and chemicals. There is a wide spectrum of severityranging from a harmless skin rash (urticaria), to potentiallyfatal airway obstruction (laryngeal oedema), and full-blownanaphylaxis (hypotension, bronchospasm). Anaphylaxis ismuch more common in adults than children.The mainstays of treatment are oxygen, adrenaline, andintravenous fluid. Steroids may prevent relapse andantihistamines provide some relief of urticarial itch but thesedrugs do nothing for the life-threatening features of acutesevere anaphylaxis.8.1.1 Treatment in adultsa. Airway and breathingAdminister high flow oxygen via face mask. Administer abronchodilator.125

Give salbutamol 5 mg via nebulizer, repeat if required.b. AdrenalineIf severe (hypotension or severe bronchospasm or stridor orhypoxia): Give adrenaline 0.5 mg (0.5 ml of 1:1,000 dilution)intramuscularly and repeat in 5 minutes if required.c. Intravenous fluids Give 0.9% saline 250 ml intravenous bolus and repeat, ifnecessary.NOTE: Large volumes of intravenous fluid may be necessaryto maintain an adequate blood pressure in severe anaphylaxis.d. Corticosteroids Give hydrocortisone succinate 200 mg intravenously,THEN 100 mg 6- hourly,OR Give prednisolone 50 mg orally daily.NOTE: All patients with significant anaphylaxis should beobserved for 24 hours as relapse may occur.126

e. Anti-histamines Give promethazine 25 mg intramuscularly followed byeither 25 mg intramuscularly or 20 mg orally three timesdaily.f. Other issues• Proper documentation of all cases.• Patient and relatives should be educated to avoidsubsequent episodes.• Patient may be provided with a medic alert bracelet.• Some patients may require adrenaline syringes for homeuse.8.1.2 Treatment in childrena. Airway and breathingAdminister high flow oxygen via a face mask. Bronchodilatorsreduce bronchospasm. Give salbutamol 2.5 mg via nebulizer in children 5 yearsof age or under; for children older than 5 years, givesalbutamol 5 mg via nebulizer; repeat if required.b. Adrenaline Give adrenaline 10 micrograms per kg mg intravenously127

over 1 minute and repeat in 5 minutes if required.NOTE: If intravenous access is not available then adrenalinemay be given via the intramuscular route. Give adrenaline 10 micrograms per kg intramuscularly.c. Intravenous fluids Give 0.9% saline 10 ml per kg bolus intravenously andrepeat as necessary.d. Corticosteroids Give hydrocortisone succinate 4 mg per kg intravenously,OR Give prednisolone 1 mg per kg orally.NOTE: All patients with significant anaphylaxis should beobserved for 24 hours as relapse may occur.e. Anti-histamines Consider the use of promethazine.128

f. Other issues• Proper documentation of all cases.• Patient and relatives should be educated to avoidsubsequent episodes.• Patient may be provided with a medic alert bracelet.• Some patients may require adrenaline syringes for homeuse.8.2 Pre-eclampsia8.2.1 Treatment of severe pre-eclampsiaa. Airway and breathingGive high flow oxygen via a face mask and obtain intravenousaccess.b. HypertensionMild elevations in blood pressure often respond to magnesiumsulphate. If the blood pressure remains high, then it should begently lowered over several hours to a level of 140/90 mmHg. Give hydrallazine 5 mg intravenously and repeat every 20minutes to a maximum of 40 mg.129

c. Seizuresi. Seizure preventionMagnesium sulphate reduces the blood pressure andhelps prevent seizures. Give magnesium sulphate 4 grams intravenouslyover 10 minutes then commence an infusion at arate of 2 grams per hour.NOTE: It is important to monitor magnesium levelsduring treatment. Clinically, hypermagnaesaemiacauses loss of deep tendon reflexes and a reduction inthe respiratory rate. If the patient becomeshyporeflexic or the respiratory rate falls below 8 perminute, then the infusion should be ceasedtemporarily. If biochemical estimation of the serummagnesium level is available, then this should bemeasured frequently, aiming for a level of between 2and 4 mmol per liter. Magnesium is superior tophenytoin, which was previously used for seizureprophylaxis.ii.Seizure managementIf seizures occur despite administration of magnesiumsulphate then conventional anticonvulsants should beused.130

Give diazepam 5 mg intravenous bolus andrepeat every 5 minutes to a maximum of 20 mg;PLUS, if seizures persist, Give phenytoin 15 mg per kg intravenously over20 minutes.NOTE: If seizures persist despite adequate levels ofmagnesium sulphate and phenytoin then the patientwill require intubation and ventilation and theadministration of a thiopentone infusion.d. Fluid balanceInsertion of a urinary catheter to monitor urine outputis essential. A central venous catheter may also beuseful. Careful administration of crystalloid solutionsis necessary to maintain urine output while avoidingpulmonary and cerebral oedema associated with overhydration.8.3 Septic ShockSeptic shock is a serious complication of bacterial septicaemia.Hypotension in this condition is a result of a combination ofabnormal vasodilation, hypovolaemia, and impaired cardiacfunction. It has a very high mortality and requires intensivetreatment, preferably in an intensive care unit. The most131

important aspect of management of septic shock is of coursetreatment of the infection with antibiotics. Other supportivetherapy may include treatment of gastrointestinal haemorrhage,renal failure, and disseminated intravascular coagulation (DIC).8.3.1 Maintain airway and breathingThe usual manoeuvres to maintain an adequate airway andadequate ventilation, up to and including endotrachealintubation should be used. All patients should at least receivehigh flow oxygen via face mask. Give oxygen to maintain an arterial oxygen saturationgreater than 95%.8.3.2 Optimise intravascular volumeVigorous administration of intravenous fluid is generallyrequired. Insertion of a central venous line is useful as itallows accurate measurement of central venous fillingpressures and also makes administration of inotropic agentssafer. Where central venous pressure monitoring isunavailable, the JVP provides an alternative indicator ofvolume status to guide fluid resuscitation. Correct anaemiawith administration of blood or otherwise use boluses ofnormal saline to achieve an optimal central venous pressure. Give 0.9% saline boluses of 100 ml intravenously to obtainan optimal central venous filling pressure.132

8.3.3 Inotropic agentsInotropic agents should only be used if significant hypotensionpersists despite adequate fluid replacement.a. Treatment in adults Give dopamine 2 micrograms per kg per minute byintravenous infusion and increase rate by 1 to 2micrograms per kg per minute every 5 minutes to amaximum of 20 micrograms per kg per minute.b. Treatment in children Give dopamine 2 micrograms per kg per minute byintravenous infusion and increase rate by 1 microgram perkg minute every 5 minutes to a maximum of 20 microgramsper kg per minute.NOTE: Ideally, inotropic agents should be infused via acentral venous line. Otherwise a large peripheral vein (such asthe femoral vein or the cubital veins) should be used.8.4 Acute PsychosisThe acutely confused and agitated patient can present adiagnostic and management problem. Often a combination oftemporary sedation and gentle physical restraint is necessary toallow the patient to be examined and assessed. However, it is133

essential that the underlying cause of the confusion is foundand treated. Sedation is not a treatment in itself.Important and treatable causes of confusion include hypoxia,hypercapnia, drug overdoses, head injuries, infections,hyponatraemia, and many other medical problems. Sedatedpatients should be closely observed. Give haloperidol 2.5 to 5 mg intramuscularly orintravenously and repeat in 10 minutes, if necessary;OR Give diazepam 5 to 10mg intravenously and repeat 30minutes later, if required;OR Give midazolam 2.5 to 5 mg intramuscularly orintravenously and repeat in 5 minutes, if necessary.NOTE: Use the lower doses in the elderly or those with bodyweights less than 50 kg.134

1. Amiodarone InfusionAppendixFormulation: 50 mg per ml ampoulePreparation: Loading dose – Mix calculated loading doseof amiodarone (5 mg per kg) in 250 ml ofdextrose 5%. Infuse for 1 to 2 hours (125 to250 ml per hour).Maintenance dose – Mix calculatedmaintenance dose of amiodarone(10 to 15 mg perkg) in 500 ml of dextrose 5%. Infuse for 24hours (20 ml per hour).Note:Amiodarone is incompatible with normalsaline solution.2. Lignocaine 1% InfusionFormulation: 1% solution (10 mg per ml) vialPreparation: Discard 400 ml from 1 liter of dextrose 5%and add 4 grams (400 ml or 40 vials oflignocaine 1%; concentration of 4 mg oflignocaine 1% per ml).135

Infusion:Time Rate (mlper hour)Dose (mgper hour)First hour 60 4Second hour 45 3After secondhour for 24hours30 23. Lignocaine 2% InfusionFormulation: 2% solution (20 mg per ml) vialPreparation: Discard 200 ml from 1 liter of dextrose 5%and add 2 grams (200 ml or 20 vials) oflignocaine 2%; concentration of 4 mg oflignocaine per ml).Infusion:Time Rate (mlper hour)Dose (mgper hour)First hour 60 4Second hour 45 3After secondhour for 24hours30 2136

4. Hydrallazine InfusionFormulation: 20 mg per ampoulePreparation: Reconstitute 20 mg ampoule by adding 2 mlof sterile water (concentration: 10 mg ofhydrallazine per ml). Add hydrallazinesolution above to 98 ml of normal saline in ametered chamber (concentration: 1 mg ofhyrallazine per ml).Infusion:Infuse initially at 0.2 to 0.3 mg per minute(12 to 18 ml per hour).5. Labetalol InfusionMaintenance dose: 0.05 to 0.15 mg perminute (3 to 9 ml per hour).Formulation: 100 mg per 20 ml (5 mg per ml)Preparation: Add 100 mg (20 ml) of labetalol in 80 ml ofdextrose 5% in a metered chamber(concentration: 1 mg of labetalol per ml).Infusion:Recommended dose – 0.5 to 2.0 mg perminute.Infusion rate – 30 ml per hour (0.5 mg per137

6. Dobutamine Infusionminute) initially then titrate at diastolic bloodpressure of 110 mm Hg is achieved to amaximum dose of 120 ml per hour (2 mg perminute).Formulation: 1 vial contains 250 mg of dobutamine inpowder formPreparation: Add 10 mg of sterile water to the 250 mg vialof dobutamine. Add the dobutamine solutionto 90 ml of normal saline or dextrose 5% in ametered chamber (concentration: 2.5 mg ofdobutamine per ml or 2,500 micrograms ofdobutamine per ml).Infusion:2.5 to 10 micrograms per kg per minute. Forexample: In a 60 to 70 kg patient, the rate ofthe dobutamine infusion will be 4 to 20 mlper hour.7. Dopamine InfusionFormulation: 1 vial contains 200 mg per 5 ml of dopaminePreparation: Add 200 mg of dopamine in 95 ml of normalsaline or dextrose 5% in a metered chamber.After reconstitution, the concentration of138

dopamine in the chamber will be 200micrograms per ml (1 ml = 60 microdrops or33 micrograms per microdrop).Infusion: To achieve enhanced renal perfusion – 2 to 5micrograms per kg per minute (120-300micrograms per minute). Forantihypotensive effect – 5 to 50 microgramsper kg per minute (300 to 3,000 microgramsper minute). For example, the infusion ratein a 60 kg patient will be 4 to 10 microdropsper minute (4 to 20 ml per hour) for renalperfusion dose and 10 to 100 ml per hour forantihypotensive effect.8. Streptokinase InfusionFormulation: 1 vial contains 1.5 million units (megaunits)of streptokinasePreparation: Add 2 ml of normal saline to the vialcontaining 1.5 megaunits of streptokinase.Mix the streptokinase solution to 98 ml ofnormal saline in a metered chamber.Infusion:100 ml per hour139

9. Isoprenaline InfusionFormulation: 2 mg per ampoule (1 mg per ml)Preparation: Add 2 mg (1 ampoule) of isoprenaline to 99ml of normal saline or dextrose 5% in ametered chamber (concentration: 0.02 mg ofisoprenaline per ml or 20 micrograms ofisoprenaline per ml).Infusion:Initially at 3 ml per hour (1 microgram perminute) then titrate accordingly based onresponse of heart rate, blood pressure, urineoutput, central venous pressure, andperipheral circulation up to a maximum of 60ml per hour (20 micrograms per minute).10. Magnesium sulphateFormulation: 50%, 2 ml (1 gram) ampoule; 10 ml (5grams) ampoulePreparation: Loading dose – Magnesium sulphate 50%, 4grams (8 ml) diluted in 100 ml of dextrose5%.Maintenance dose – Magnesium sulphate50% (25 ml) in 100 ml dextrose 5%.140

Infusion:Loading dose – Use infusion pump and run at300 ml per hour and set total volume at 108ml.Maintenance dose – Infuse at 1 gram perhour. Set infusion pump to run at 10 ml perhour and set total volume at 125 ml.141